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DKA and HHS: Critical Care and Mortality Management

Learn about the difference between DKA and HHS, their management, fluid therapy, insulin therapy, potassium management, and potential complications.

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DKA and HHS: Critical Care and Mortality Management

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  1. DKA/HHS Paul Szczybor PA-C DFAAPA Lifebridge Critical Care

  2. Mortality • DKA 2-5% • HHS 15% • DKA…Most common cause of death in adolescents and children with DM Type 1Accounts for ½ deaths in diabetic patients <24 years Guillermo E. Umpierrez, MD, FACP, Mary Beth Murphy, RN, MS, CDE, MBA, Abbas E. Kitabchi, PhD, MD, FACP, FACE. Diabetes Spectrum 2002 Jan; 15(1): 28-36. https://doi.org/10.2337/diaspect.15.1.28

  3. Lamar • 33 year old hx “pre-diabetes”, recent pneumonia, no meds • Progressive weakness, excessive thirst, change in mental status • Lethargic, difficult to arouse but oriented to person/place • BP 120/70 HR 116 RR 28 T 37.2° • Dry oral mucosa, neck: supple, lungs: few coarse crackles R base, heart: regular, abdomen: benign, extremities: no edema

  4. Lamar 126 94 42 1008 5.8 18 1.7 β-hydroxybutyrate 1.0 mmol/L

  5. DKA vs HHS DKA HHS Glucose > 600 mg/dL Serum CO2 > 15 mEq/L Anion Gap < 12 Serum Osmo > 320 mOsm/kg Alteration in mental status • Glucose > 250 mg/dL • Serum CO2 < 18 mEq/L • Anion Gap > 12 • Serum Osmolality variable 1/3 cases overlap Kitabchi A, et al. Diabetes Care, 2006, 29: 2739-2747

  6. Lamar 126 94 42 1008 5.8 18 1.7 β-hydroxybutyrate 1.0 mmol/L

  7. Hyponatremia 1) Pseudohyponatremia • SIADH • Hyperosmolar hyponatremia • Water intoxication

  8. Serum Osmolality 2Na⁺ + Glucose + BUN 18 2.8 Normal 285-295

  9. Intravascular Extravascular Serum Osmolality ↑glucose ↑osmolality 2Na⁺ + Glucose + BUN 18 2.8 H2O ↓Na⁺ ↓H2O

  10. Sodium Correction in Hyperglycemia “Classic” 1.6 mEq/L Na⁺ for every 100 mg/dL Glucose Hillier 2.4 mEq/L Na⁺ 100 mg/dL Glucose

  11. Goals of Treatment • DKA- Vigorously rehydrate patient - Promote ketolysis- Correct hyperglycemia • HHS- Vigorously rehydrate patient- Correct hyperglycemia- Treat underlying diseases

  12. Fluid Therapy • Total Body Water DeficitDKA 100 mL/kgHHS 100-200 mL/kg • Initial fluid replacement: Normal saline 15-20 mL/kg/hr • Average adult:- 1st hour 1-3 liters- 2nd hour 1 liter- Next 2 hours 500 mL/hr- then 250 mL/hr

  13. Insulin Therapy • DKA- It’s not about the blood sugar… necessary for ketolysis- IV hydration first then- Regular insulin (0.1 unit/kg/hr)- Follow the anion gap (BMP q4h)- Add Dextrose when glucose < 300mg/dL • HHS- Many patients will respond to IV fluid alone!- Do not start insulin until adequately hydrated

  14. Potassium • Intracellular shifts • Aggressive replacement frequently needed • Do not start insulin if serum K ≤ 3.3

  15. Bicarbonate • Rarely needed • Only consider as a life saving measure • Paradoxical cellular acidosis

  16. Ketones • β-hydroxybutyrate • Acetoacetate • Acetone

  17. Complications • Cerebral edema • Cardiac arrhythmia • Pulmonary edema • Myocardial injury • Hypokalemia • Hypoglycemia • Diabetic retinopathy

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