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

Mortality DKA 2-5% HHS 15% DKA… Most common cause of death in adolescents and children with DM Type 1 Accounts 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

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

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

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

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

Hyponatremia 1) Pseudohyponatremia SIADH Hyperosmolar hyponatremia Water intoxication

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

H2O Extravascular Intravascular Serum Osmolality 2Na⁺ + Glucose + BUN 18 2.8 H2O ↓Na⁺ ↓H2O

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

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

Fluid Therapy Total Body Water Deficit DKA 100 mL/kg HHS 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

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

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

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

Ketones β-hydroxybutyrate Acetoacetate Acetone

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