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TABLE 51-7 Comparison of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome



Characteristics DKA HHS


Patients most Can occur in type 1 or Can occur in type 1 or type 2 diabetes;
commonly affected type 2 diabetes; more more common in type 2 diabetes,
common in type 1 especially older patients with type 2
diabetes diabetes


Precipitating event Omission of insulin; Physiologic stress (infection, surgery,
physiologic stress stroke, MI)
(infection, surgery, stroke,
MI)


Onset Rapid (<24 hours) Slower (over several days)


Blood glucose Usually >250 mg/dL (>13.9 Usually >600 mg/dL (>33.3 mmol/L)
levels mmol/L)


Arterial pH level <7.3 Normal


Serum and urine Present Absent
ketones




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Serum osmolality 300–350 mOsm/L >350 mOsm/L


Plasma bicarbonate <15 mEq/L Normal



TABLE 51-7 Comparison of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome



Characteristics DKA HHS


level


BUN and Elevated Elevated
creatinine levels


Mortality rate 1%–5% 10%–20%


DIABETIC KETOACIDOSIS

12. What is diabetic ketoacidosis?

Usually occurs less than 30 years of age and has rapid onset (<24 hours)

Caused by an absence or inadequate amount of insulin, it results in disorders in the
metabolism of carbohydrates, protein, and fat. The 3 main clinical features of DKA are
*Hyperglycemia, *dehydration and electrolyte loss, and *Acidosis

Without insulin glucose remains in bloodstream and liver releases glucose causing
hyperglycemia. The kidneys try to excrete excess glucose causing osmotic diuresis and
polyuria leading to Dehydration and electrolyte loss, they can lose up to 6.5 liters of
water and 400 to 500 meq of Na, K, and Chloride in a 24 hour period. The body breaks
down fat which is converted to ketones which are acids leading to Metabolic acidosis.

Onset is 4-10 hours

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13. What are the 3 main causes of Diabetic Ketoacidosis?

Decreased or missed dose of

insulin Illness or infection

Undiagnosed diabetes


Other causes are skipping insulin dose, not drawing up correct dose, pancreatitis,
cocaine, MI, pregnancy, and new medications-prednisone, antipsychotics, high dose
hctz, older age

**remember infection and insulin causes increased glucose so patients do not need
to decrease the insulin dose to compensate for decreased food intake when ill and
may need to increase insulin-during stress body releases hormones that increase
sugar**

14. How can you prevent DKA?

When you are ill never eliminate insulin, and consume frequent small portions of carbs
(juices, sodas and gelatin, drinking more fluids every hour is important to prevent
dehydration, assess blood glucose and urine ketones every 3-4 hours

Guidelines to follow when ill-take insulin as usual, gest glucose and ketones q 3-4 hrs,
report elevated glucose or ketones to provider, may need supplemental regular insulin
q 3-4 hours, substitute soft foods- gelatin, cream soup, custard, and graham crackers 6-
8 times daily, take liquids-cola, orange juice, broth, Gatorade every ½ to 1 hour, if you
can not take fluids without vomiting or sugar and ketone levels stay high contact
provider
( need a sick day kit-urine ketone test, snacks, access to contact provider)

15. What are symptoms of DKA?

Polydipsia, polyuria, fatigue, blurred vision, weakness, h/a, orthostatic hypotension,
tachycardia, anorexia, n/v, abdominal pain, fruity breath, kussmaul respirations,
hyperventilation, and mental status in DKA varies widely may be alert, lethargic or
comatose

Blood sugar levels are between 300-800

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Low serum bicarbonate (0-15) and low PH(6.8-

7.3) Low PCO2 (10-30)

Elevated ketones in urine

Na may be low, normal or high

Elevated potassium

Elevated BUN and

Creatinine Elevated

hematocrit


16. How is DKA treated?

Correct hyperglycemia, dehydration, electrolyte loss and acidosis

Rehydration-may need 6-10 L of IV fluid to replace fluid loss, initially 0.9% of NS
administered rapidly at 0.5 liters/hour for 2-3 hours, 0.45 NS may be given for patients
with hypertension or hypernatremia and those at risk for heart failure, after the first few
hours 0.45% NS is continued if b/p is stable and Na level not low, moderate to high rates
of infusion 200-500 ml per hr may be deeded for several more hours, when glucose level
reaches 300 will be changed to D5W to prevent decline in glucose, monitor b/p and
heart rate, lungs and I&O frequently, plasma expanders may be necessary to correct
severe hypotension, monitor for fluid overload in older, renal impairment or heart
failure

Restoring electrolytes-monitor potassium level frequently- rehydration leads to
increased plasma volume and decreases in potassium, insulin administration will move
potassium back in cells, cautious but timely potassium replacement is vital to avoid
dysrhythmias that occur with hypokalemia. As much as 40 meq per hr may be needed
for several hours, potassium is administered even if plasma potassium normal because
rehydration decreases potassium. Frequent Q2-3 hrs EKGs and lab measurements are
necessary for the 1st 8 hours. Potassium is only withheld with hyperkalemia and
patient is not urinating. Because the potassium level drops with rehydration
potassium replacement must begin once potassium levels drop to normal

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