Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State 3/1/2022 SBEM Asir , Abha , Saudi Arabia Asir Central Hospital

1. DIABETIC KETOACIDOSIS
Dr. Haitham S Habtar
MD, SBEM PGY-2

2. 2
Epidemiology
 DKA is more common in patients with type 1 than type 2 diabetes, by a ratio of approximately 2:1
 the prevalence of DKA in patients with type 1 diabetes was between 50 and 100 per 1,000 person-years
 The mortality rate in DKA is less than 1% in adults but higher in very young and very old people. Mortality
rates have been steadily decreasing because of increased recognition and improved management algorithms

3. PATHOPHYSIOLOGY
3

4. DIAGNOSTIC CONSIDERATIONS
Clinical Presentation
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• Symptoms are often non-specific in early diabetic emergencies
• Gastrointestinal complaints are common in patients in DKA. Abdominal pain was found to be present in 46%
of patients in DKA in one study, and it appeared to correlate with the amount of acidosis present
• Patients in DKA often do not mount a fever, even in the setting of infection.
• Patients are clinically dehydrated on exam, and adults average a fluid deficit of 6 L

5. DIAGNOSTIC CONSIDERATIONS
Laboratory Evaluation
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7. THERAPEUTIC CONSIDERATIONS
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• IV fluid resuscitation
• Insulin infusion should be initiated after the
potassium level is known , Insulin infusion
should be started at 0.1 units/kg/h
• The target of insulin therapy in DKA is
resolution of acidosis (not resolution of
hyperglycemia), and insulin should be
continued until two of the following are
found on repeat lab draws:
 serum bicarbonate ≥15 mEq/L (≥15
mmol/L)
 pH >7.3,
 anion gap ≤12 mEq/L (≤12 mmol/L)
• NaCHO3 ?!!

8. 8
IV Fluid ???
• The recommended fluid is isotonic crystalloid; 0.9% sodium chloride has been recommended by several
governing bodies as the fluid of choice
the study comparing 0.9% normal saline
with Plasmalyte
indicated less potassium and faster
resolution of the acidosis in patients who
received Plasmalyte

9. 9
Case
23 Y/O Female K/C as type 1 DM came to ER complain from Abd. Pain and Vomiting for 1day
HR: 110 BP : 102/73 O2 : 98% on RA RR: 26
RBS : 168 mg/dL
VBG
PH : 7.02 PCo2 : 32 K+: 3.2 Na: 130 HCO3 : 10
UDS :
glucose +++
Ketone ++

10. EUGLYCEMIC DKA
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11. COMPLICATION
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•Diagnosis of cerebral edema is clinical, the patient has one diagnostic criterion, two major
criteria, or one major and two minor criteria as follows:
• Diagnostic criteria
• Posturing
• Abnormal response to pain
• Cranial nerve palsy
• Neurologic respiratory pattern
• Major criteria
• Altered or fluctuating mental status
• Sustained decrease in heart rate of 20 bpm without an obvious cause such as fluid
resuscitation
• Incontinence in a normally continent patient
• Minor criteria
• Vomiting (after treatment, if the patient initially presented with vomiting)
• Headache
• Lethargy
• Diastolic blood pressure >90 mm Hg
• Age <5 y

13. HYPEROSMOLAR HYPERGLYCEMIC
STATE
HHS

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Epidemiology
• Hyperosmolar hyperglycemic state is less common than diabetic ketoacidosis (DKA). Less than 1% of
hospital admissions of patients with diabetes have been estimated to be for hyperosmolar hyperglycemic
state
• Hyperosmolar hyperglycemic state is much more common in people with type 2 diabetes, but it also occurs
in people with type 1 diabetes.
• Hyperosmolar hyperglycemic state has a higher mortality rate than DKA, with estimates between 10% and
20%.
• Most patients who present with hyperosmolar hyperglycemic state are older. However, there are reports of
patients throughout the spectrum, even in the pediatric population.

15. PATHOPHYSIOLOGY
15

16. DIAGNOSTIC CONSIDERATIONS
Clinical Presentation
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• Symptoms are often non-specific in early diabetic emergencies
• Gastrointestinal complaints are less common in patients in hyperosmolar hyperglycemic state than in DKA
• Patients in HHS often do not mount a fever, even in the setting of infection.
• Patients are clinically dehydrated on exam, and adults average a fluid deficit of 9 L
• The time course for hyperglycemic crises can help differentiate between hyperosmolar hyperglycemic state
and DKA: hyperosmolar hyperglycemic state usually develops over weeks, whereas DKA usually develops
rapidly, over hours to days

17. DIAGNOSTIC
CONSIDERATIONS
Clinical Presentation
17

18. DIAGNOSTIC CONSIDERATIONS
Laboratory Evaluation
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19. Osmolality Na
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20. THERAPEUTIC
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• IV fluid resuscitation
• Insulin infusion
should be initiated
after the potassium
level is known ,
Insulin infusion
should be started at
0.05 units/kg/h
• The target for insulin
therapy in
hyperosmolar
hyperglycemic state
is resolution of the
osmolarity and
improvement in
mental status

21. REFERENCES
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