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.

Monitoring

Adult diabetic ketoacidosis (DKA)

  • Check glucose, blood urea nitrogen (BUN), creatinine, & electrolytes every 2-4 hours until stable
  • Continue to investigate precipitating causes & treat appropriately

Criteria for Resolution of DKA:

  • Blood glucose <200 mg/dL
  • Venous pH >7.3
  • Bicarbonate ≥15 mEq/L

After Resolution of DKA:

  • If patient is nothing by mouth/non per os (NPO), continue intravenous (IV) insulin & supplement w/ Regular insulin subcutaneous (SC) as required every 4 hours

Once patient is able to eat:

  • Start multidose insulin regimen & adjust as required
  • IV insulin should be continued for 1-2 hours after SC insulin is started

Adult hyperosmolar hyperglycemic state (HHS)

  • Check BUN, creatinine, electrolytes, & glucose every 2-4 hours until stable
  • Continue to investigate precipitating causes & treat appropriately

After Resolution of HHS:

  • If patient is NPO continue IV insulin & supplement w/ SC insulin as required

Once patient is able to eat:

  • Start multidose insulin regimen (such as SC), or give as previous treatment & check metabolic control

Pediatric DKA & HHS

  • Check glucose & electrolytes every 2-4 hours until stable
  • Continue to investigate precipitating causes & treat appropriately

After Resolution of DKA:

  • Start SC insulin (0.5-1 U/kg/day)
    • Give 2/3 of the total daily dose in the AM (1/3 short-acting & 2/3 of dose intermediate-acting insulin)
    • Give 1/3 of total daily dose in the PM (1/2 short-acting & 1/2 of dose intermediate-acting insulin)
  • Or give 0.1-0.25 U/kg SC of Regular insulin every 6-8 hours for the first 24 hours to determine insulin requirements
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