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diabetic%20ketoacidosis%20-and-%20hyperosmolar%20hyperglycemic%20state

DIABETIC KETOACIDOSIS & HYPEROSMOLAR HYPERGLYCEMIC STATE

Diabetic ketoacidosis is characterized by having blood glucose >13.9 mmol/L, arterial pH <7.3 in adults or venous pH <7.3 in pediatrics, bicarbonate <15 mEg/L, moderate ketonuria or ketonemia and anion gap >14.
Hyperosmolar hyperglycemic state in adults is described as having blood glucose >33.3 mmol/L, arterial pH >7.3, bicarbonate >15 mEq/L, mild ketonuria or ketonemia, effective serum osmolality >320 mOsm/kg and variable anion gap.
Hyperosmolar hyperglycemic state in pediatric patients has blood glucose >33.3 mmol/L, venous pH >7.3, bicarbonate >15 mEq/L and altered mental status or severe dehydration.

Diabetic%20ketoacidosis%20-and-%20hyperosmolar%20hyperglycemic%20state Diagnosis

Diagnosis

Evaluation

Diagnostic Criteria for diabetic ketoacidosis (DKA)

Blood glucose >13.9 mmol/L (>250 mg/dL)
Arterial pH <7.3 in adults or venous pH <7.3 in pediatrics
Bicarbonate <15 mEq/L
Moderate ketonuria or ketonemia
Anion gap >12

Diagnostic Criteria for hyperosmolar hyperglycemic state (HHS) in Adults

Blood glucose >33.3 mmol/L (>600 mg/dL)
Arterial pH >7.3
Bicarbonate >15 mEq/L
Mild ketonuria or ketonemia
Effective serum osmolality >320 mOsm/kg
Anion gap variable

Diagnostic Criteria for HHS in Pediatrics

Blood glucose >33.3 mmol/L (>600 mg/dL)
Venous pH >7.3
Bicarbonate >15 mEq/L
Altered mental status or severe dehydration

Classification

Classification of Diabetic Ketoacidosis

Mild DKA presents without alteration in sensorium, > 250 mg/dL plasma glucose, arterial pH 7.25-7.30, 15-18 mEq/L serum bicarbonate, presence of serum & urine ketones, & >10 anion gap
Moderate DKA presents w/ or without alteration in sensorium or drowsiness, >250 mg/dL plasma glucose, arterial pH 7-<7.24, 10-<15 mEq/mL serum bicarbonate, presence of serum & urine ketones, & >12 anion gap
Severe DKA presents w/ stupor or coma, >250 mg/dL plasma glucose, arterial pH <7, <10 mEq/L serum bicarbonate, presence of serum & urine ketones, & >12 anion gap

History

History of polyuria, polydipsia, polyphagia, weight loss, vomiting, abdominal pain (in DKA)
Dehydration
Weakness

Physical Examination

Altered mental status or sensoria clouding to coma (more frequent in HHS)
Poor skin turgor, dry axilla & oral mucosa, Kussmaul respirations (in DKA), low jugular venous pressure, tachycardia, hypotension, shock

Laboratory Tests

Serum glucose
Blood urea nitrogen (BUN)/creatinine
Serum ketones
Electrolytes (anion gap)
Serum osmolality
- Effective osmolality = (2 × Na) + (glucose/18)
Urinalysis
ECG &/or chest X-ray (CXR), if indicated
Urine ketones by dipstick
Arterial blood gas
CBC w/ differential
Urine, blood & throat culture
Glycosylated hemoglobin (HbA_1c)
Nitroprusside testing

High dose comparable to lower doses of ACE inhibitors for heart failure

Jairia Dela Cruz, 16 Sep 2020

In patients with heart failure with reduced ejection fraction (HFrEF) receiving angiotensin-converting-enzyme (ACE) inhibitors, high dosing confers benefits for the risk of death or hospitalization that are similar to that obtained with lower dosing, according to a systematic review and meta-analysis.