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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.

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 (HbA1c)
  • Nitroprusside testing
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