1. Paul Szczybor PA-C DFAAPA Lifebridge Critical Care
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 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. 

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
β-hydroxybutyrate 1.0 mmol/L

5. 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:

6. Lamar
β-hydroxybutyrate 1.0 mmol/L

7. Hyponatremia 1) Pseudohyponatremia SIADH Hyperosmolar hyponatremia
Water intoxication

8. Serum Osmolality
2Na⁺ + Glucose + BUN
Normal

9. H2O Extravascular Intravascular Serum Osmolality 2Na⁺ + Glucose + BUN
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⁺ 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 Deficit DKA 100 mL/kg HHS 100-200 mL/kg
Initial fluid replacement: Normal saline 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