Diabetic

Ketoacidosis and Hyperglycaemic Hyperosmolar State

Diabetic ketoacidosis Hypergylcaemia
Hyperosmolar State
Definitions State of absolute or relative Relative insulin def resulting
insulin deficiency in marked hyperglycaemia
but without ketone
formation
Clinical features Onset is over a Occurs in T2DM
period of days Could be initial
(acute) presentation of
Polyuria, polydipsia, diabetic state
nocturia Patients are often
Weight loss elderly
Hyperventilation May present with
Acetone breath obtundation to coma
Vomiting Severe dehydration
Abdominal pain invariable
Dehydration May have associated
Hypotension lactic acidosis
Drowsiness Precipitating factors
coma similar to DKA
High mortality
Precipitating factors Stopping insulin or reducing the dose
New onset of T1DM
Stress, with increasing insulin resistance &
requirement (trauma, infection, surgery, MI and
stroke)
Investigation Diagnosis Diagnosis
RBS 14 mmol/L Blood glucose 33
ABG : pH <7.3 ; HCO3 mmol/L
<15mmol/L ABG:pH >7.3;HCO3
Ketonaemia >18mmol/L
(>3mmol/L) or Absence of
ketonuria (2+) ketonuria or
ketonaemia
FBC
RP (Na, K, urea,
creatinine)
Ix to delineate cause
(CXR, infective
screen, ECG, urine
microscopy,
amylase)
Management Fluid therapy
6-8L in DKA and 9L in HHS
regime for moderately dehydrated patients
 Normal saline of 0.9% (154mmol/L NaCl)
o 1L in 1 hr
o 1L in 2 hr
o 1L in 4hr
o 1L in 6hr
o 1L in 8hr
Monitor the response by clinical state and lab
result. Monitor CVP especially in older pt or when
massive replacement is require
If pt is in shock, fluid is either NS or colloids
administered at suitable rate
If serum Na is >145 mmol/L, use 0.45% NaCl
If glucose <15mmol/L, ise
Fluid containing glucose (dextrose saline) or
5.10% dextrose water or
alternating dextrose saline and 5% dextrose
depending on N level *use 10% dextrose if
persisting acidosis)

Insulin therapy
Continuous IV insulin infusion
Soluble insulin diluted in 0.9% saline at
concentration of 1 U/ml
Give bolus 10U soluble insulin then followed by
6U/hr by infusion pump or paediatric drip set
Monitor glucose hourly->aims for drop of glucose
10%
Slow response suggest inadequate fluid therapy
If adequate fluid therapy, the double the infusion
rate
When glucose <15mmol/L, change to dextrose
solution and halve the infusion rate, Aim glucose
around 8-12 mmol/L in DKA an 14-16mmol/L in
HHS ( until plasma osmolality <315mmol/L and pt
mentally alert)
Cont infusion until metabolic acidosis resolve

Electrolytes replacement
Potassium
Dont give without knowing the level
Start immediately if ECG shows no hyperK, ample
urine output, when plasma K<5mmol/L
Add 1g KCL every 0.5L of fluid
Monitor BUSE 4-6 hr and ECG monitoring
Maintain K 4-5 mmol/L

 Bicarbonate and correction of acidosis
Mixed with NS and give 1-2 ml NaHCO3 per Kg BW over 30
minutes and recheck ABG

Phosphate
Replace if presence of anaemia, cardiac and respiratory
dysfunction

Correct the precipitating factors
Broad spectrum antibiotic if necessary

Beware of DKA complication
Hypoglycaemia
Cerebral oedema
Arterial and venous thrombosis (SC heparin 5000U
BD)
Hypokalaemia
Gastric dilatation

*for HHS
fluid regime should be less rapid
when glucose is <15mmol/L, halve the insulin
infusion rate and use 5% dextrose in pt with
persistent hyperosmolality and hypernatraemia
with frequent Na monitoring.
Consider heparinising patient for 2-3 days to
prevent venous and arterial thromboses.
When stress and HHS resolve, may discharged pt
with OAD.
Recovery Long term insulin therapy in most cases except DKA
induced by severe stress
In HHS, pt might be able to discharged with OHA
Change infusion from to SC insulin
Cont infusion until acidosis resolve and negative
ketonuria
Ask pt to eat, give SC insulin while maintaining
(overlap) the infusion for 1hr after the first SC
insulin dose
Start with immediate acting insulin ON, and short
acting insulin three times before meal
Monitor blood glucose prebed and premeal and
adjust insulin accordingly





DKA HHS
Mild Moderate Severe
pH 7.25-7.30 7.00 to <7.25 <7.0 >7.30
bIcarbonate 18-15 15-10 <10 >18
Urine ketone +ve +ve +ve Small
Serum ketone +ve +ve +ve small
Effective serum variable variable Variable >320mOsm/kg
osmolality
Anion gap >10 >12 >12 Variable
Mental status alert Alert/drowsy Stupor/coma Stupor/coma