Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State


Epidemiology

Diabetic Ketoacidosis (DKA)

  • Highest Risk Group: most commonly occurs in patients with type 1 diabetes mellitus (see Diabetes Mellitus, [[Diabetes Mellitus]])
  • Average Age of Onset: 30’s
  • Mortality Rate: lower than HHS

Precipitating Factors for Diabetic Ketoacidosis

  • Insulin/Medication Non-Compliance
    • Includes Malfunction of Subcutaneous Insulin Pumps
  • New-Onset Diabetes Mellitus (see Diabetes Mellitus, [[Diabetes Mellitus]]): 20-25% of cases
  • Infection/Sepsis (see Sepsis, [[Sepsis]])
  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
  • Myocardial Infarction (MI) (see Coronary Artery Disease, [[Coronary Artery Disease]])
  • Drugs
    • Anti-Psychotics
      • Clozapine (Clozaril) (see Clozapine, [[Clozapine]])
      • Olanzapine (Zyprexa) (see Olanzapine, [[Olanzapine]])
    • Lithium (see Lithium, [[Lithium]])
    • Sympathomimetics: these agents alter carbohydrate metabolism

Hyperosmolar Hyperglycemic State (HHS)

  • Highest Risk Group: most commonly occurs in patients with type 2 diabetes mellitus (see Diabetes Mellitus, [[Diabetes Mellitus]])
    • Usually Associated with a Concomitant Illness with Associated Decrease in Oral Intake
  • Average Age of Onset: 57-69 y/o
  • Mortality Rate: higher than DKA
    • Mortality Rate in HHS Can Be as High as 10-20%

Precipitating Factors for Hyperosmolar Hyperglycemic State


Physiology

Diabetic Ketoacidosis (DKA)

Fate of Ketoacids (Acetoacetate, ß-Hydroxybutyrate) During Treatment of DKA

Hyperosmolar Hyperglycemic State (HHS)

Mechanisms of Insulin Resistance


Diagnosis


Clinical Manifestations of Diabetic Ketoacidosis (DKA)

General Comments

Cardiovascular Manifestations

Constitutional Manifestations

Endocrinologic Manifestations

Gastroenterologic Manifestations

Hematologic Manifestations

Neurologic Manifestations

Pulmonary Manifestations

Renal Manifestations

Abnormal Serum Phosphate (with Associated Phosphate Depletion)

Abnormal Serum Potassium (with Associated Potassium Depletion)

Abnormal Serum Sodium

Ketonemia (see Ketonemia, [[Ketonemia]])

Ketonuria (see Urinalysis, [[Urinalysis]])

Metabolic Acidosis

Elevated Osmolal Gap (see Serum Osmolality, [[Serum Osmolality]])

Polydipsia (see Polydipsia, [[Polydipsia]])

Polyuria (see Polyuria, [[Polyuria]])


Clinical Manifestations of Hyperosmolar Hyperglycemic State

General Comments

Cardiovascular Manifestations

Endocrinologic Manifestations

Gastrointestinal Manifestations

Neurologic Manifestations

Renal Manifestations

Abnormal Serum Phosphate (with Associated Phosphate Depletion)

Abnormal Serum Potassium (with Associated Potassium Depletion)

Abnormal Serum Sodium

Ketonemia (see Ketonemia, [[Ketonemia]])

Ketonuria (see Ketonuria, [[Ketonuria]])

Metabolic Acidosis

Hyperosmolality (see Serum Osmolality, [[Serum Osmolality]])

Polydipsia (see Polydipsia, [[Polydipsia]])

Polyuria (see Polyuria, [[Polyuria]])


Treatment

Diabetic Ketoacidosis (DKA)

Protocol-Driven Care

Intravenous Fluid Resuscitation

Insulin Administration (see Insulin, [[Insulin]])

Repletion of Serum Phosphate

Repletion of Serum Potassium

Sodium Bicarbonate (see Sodium Bicarbonate, [[Sodium Bicarbonate]])

Monitoring of Diabetic Ketoacidosis Therapy

Complications of Diabetic Ketoacidosis Therapy

Hyperosmolar Hyperglycemic State

Intravenous Fluid Resuscitation

Insulin Administration (see Insulin, [[Insulin]])

Repletion of Serum Phosphate

Repletion of Serum Potassium

Monitoring of Hyperosmolar Hyperglycemic State Therapy

Complications of Hyperosmolar Hyperglycemic State Therapy


References