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.

Pharmacotherapy

  • DKA & HHS patients are best managed in the intensive care unit w/ the care of a specialist/endocrinologist

Intravenous (IV) Fluids

  • Initial therapy aims to restore renal perfusion, & expand intravascular & extravascular volume
  • Fluid deficits should be corrected w/in the first 24 hours of treatment
  • Serum Na should be corrected for hyperglycemia (for each 5.6 mmol/L glucose >5.6 mmol/L, add 1.6 mmol to Na value for corrected serum Na value)
  • Serum osmolality change should not be >3 mOsm/kg H2O/hour
  • Avoid iatrogenic fluid overload by frequently monitoring cardiac, renal & mental status
  • In pediatric patients, initial fluid expansion should not be >50 mL/kg over first 4 hours of treatment
    • Fluid deficits should be corrected over 48 hours of treatment

Insulin

  • Ketonemia usually takes longer to clear than hyperglycemia
  • May or may not be aggressive w/ insulin administration depending on patient hydration
  • If patient presents w/ severe hypokalemia, insulin treatment should be delayed until K serum concentration is restored to >3.3 mmol/L to avoid respiratory arrest & arrhythmias
  • There should be an overlap of IV insulin & subcutaneous (SC) insulin of 1-2 hours to ensure adequate glucose control
    • An abrupt discontinuation of IV insulin w/ a delayed onset of SC insulin may result in inadequate glucose control
  • In newly diagnosed diabetics the initial total insulin dose should be ~0.5-1 U/kg/day given in ≥2 divided doses
    • Include both short-acting & long-acting insulin
    • Continue until optimal dosing is established

Potassium

  • Correction of acidosis, volume expansion & insulin therapy decrease serum K concentration
    • Hypokalemia may be avoided by K replacement 

Bicarbonate

  • Studies have failed to show benefit or deleterious changes in morbidity or mortality w/ bicarbonate use in diabetic ketoacidosis (DKA) patients w/ pH between 6.9-7.1
  • Insulin & bicarbonate can lower serum K & supplementation may be required

Phosphate

  • Patients w/ cardiac dysfunction, anemia or respiratory depression may benefit from careful phosphate replacement
    • Hypophosphatemia may cause cardiac & skeletal muscle weakness, & respiratory depression

Somatostatin

  • Though not considered standard therapy, Somatostatin may be added if patients are resistant to conventional DKA therapy
  • Effects: Decrease glucagon secretion & inhibit ketogenesis
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