DKA and HHS

Definitions:

• Diabetic ketoacidosis (DKA)^1,2– uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketones
• Hyperosmolar hyperglycemic state (HHS)^1,2– severe hyperglycemia, hyperosmolality, and dehydration in the absence of significant ketoacidosis

	DKA, Mild	DKA, Moderate	DKA, Severe	HHS
Plasma Glucose (mg/dl)	>250	>250	>250	>250
Serum Bicarb (mEq/L)	15-18	10 to <15	<10	>18
Urine Ketones	Positive	Positive	Positive	Small
Serum Ketones	Positive	Positive	Positive	Small
Serum Osm. (mOsm/kg)	Variable	Variable	Variable	>320
Anion Gap	>10	>12	>12	Variable
Mental Status	Alert	Alert, Drowsy	Stupor, Coma	Stupor, Coma

Treatment:

1. Fluid resuscitation:^1,2
   • NS (0.9%NaCl) 15-20 ml/kg or 1-1.5 liters in first hour … THEN
   • If corrected serum Na is low, cont. NS @ 250-500 ml/hr
   • If corrected serum Na is high or normal, change to 0.45% NaCl @ 250-500 ml/hr
   • Once plasma glucose reaches 200  mg/dl (DKA) or 300 mg/dl (HHS) change to 5%dextrose/0.45%NaCl @150-200 ml/hr
2. Potassium:^1,2,3 (Hold insulin until K⁺ level is known)
   • Establish urine output 50 ml/hr
   • K⁺ > 5.2 mEq/L – no replacement, recheck q2 hours
   • K⁺ 3.3-5.2 mEq/L – give 20-30 mEq K⁺ in each liter of IVF to maintain serum K⁺ between 4-5 mEq/L. Consider oral replacement.
   • K⁺ < 3.3 mEq/L – HOLD INSULIN and give 20-30 mEq K⁺ per hour until serum level > 3.3 mEq/L. Consider oral replacement.
3. Insulin:
   • Start Infusion (no bolus^3,4) 0.1-0.14 units/Kg/hr^1,2,3,4
   • DKA^1,2– when serum glucose is 200, maintain plasma glucose 150-200 until resolution of ketoacidosis
     • Reduce insulin to 0.02-0.05 units/Kg/hr OR
     • Change to rapid acting subcutaneous insulin 0.1U/Kg every 2 hours
   • HHS^1,2– when serum glucose is 300, maintain plasma glucose 200-300 until patient alert.
     • Reduce insulin to 0.02-0.05 units/Kg/hr OR
     • Change to rapid acting subcutaneous insulin 0.1U/Kg every 2 hours
4. Replete electrolytes:
   • Magnesium level should be corrected in hypokalemic patients.
   • Serum phosphate concentration <1.0 mg/dl may be repleated with 20–30 mEq/l potassium phosphate mixed with IVF. ^1,2

• Most commonly infection^1,2
• Inadequate insulin or discontinuation^1,2
• Pancreatitis^1,2
• MI^1,2
• CVA^1,2
• Drugs^1,2
  • corticosteroids
  • thiazides
  • sympathomimetic agents
  • antipsychotics
  • pentamidine

Mortality:

• DKA:^1,2
  • <1% Adults
  • DKA is the most common cause of death in children and adolescents with type 1 diabetes and accounts for half of all deaths in diabetic patients younger than 24 years of age
  • >5% has been reported in the elderly and in patients with concomitant life-threatening illnesses
• HHS: 5-20%^1,2

Other Considerations:

• VBG is equivalent to ABG and adequate for use in DKA and HHS.^7,8,9,10 However, ABG analysis rarely changes management in the ED. ⁸ (See VBG vs ABG)
• IV bicarbonate therapy does not show an improvement in patient oriented outcomes.^5,6
• Insulin bolus increases risk of hypoglycemic event without improving patient oriented outcomes.^3,4
• Measurement of Beta-hydroxybutyrate has been shown to be accurate for the diagnosis of DKA in adults and children. A level >3.8 mmol/L in adults or >3.0 mmol/L in children is diagnostic.¹¹

Sources:

1. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crisis in adult patients with diabetes. Diabetes Care. 2009;32(7):1339. PubMed , Open Access
2. Westerberg DP. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013;87(5):337-46. PubMed , Open Access
3. Arora S, Cheng D, Wyler B, Menchine M. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med. 2012;30(3):481-4. PubMed
4. Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010;38(4):422-7. PubMed
5. Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Ann Intensive Care. 2011;1(1):23. PubMed
6. Duhon B, Attridge RL, Franco-martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013;47(7-8):970-5. PubMed
7. Kelly AM. Review article: Can venous blood gas analysis replace arterial in emergency medical care. Emerg Med Australas. 2010;22(6):493-8.  PubMed
8. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10(8):836-41. PubMed
9. Bloom BM, Grundlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2014;21(2):81-8. PubMed
10. Menchine M, Probst MA, Agy C, Bach D, Arora S. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department. Acad Emerg Med. 2011;18(10):1105-8. PubMed
11. Sheikh-Ali M, Karon BS, Basu A, Kudva YC, Muller LA, Xu J, Schwenk WF, Miles JM. Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis? Diabetes Care. 2008 Apr;31(4):643-7. PubMed

Further Reading:

1. DKA Myths – Rebel EM Salim Rezaie
2. Myths of DKA Management – EMDocs Anand Swaminathan
3. DKA Myths – EM:RAP Anand Swaminathan
4. Correction Of Critical Hypokalemia – EM Updates  Reuben Strayer
5. Bicarb in DKA – EMCrit Josh Farkas
6. Sodium Bicard in DKA – Rebel EM  Darrel Hughes
7. Insulin Bolus in DKA – Rebel EM Darrel Hughes
8. Blood Gas in DKA – EMCrit Josh Farkas