DKA & HHS

Type 1 Diabetes Mellitus

- Beta cell destruction leading to absolute insulin deficiency

- Autoimmune

- Idiopathic

Type 2 Diabetes Mellitus

Ranges from insulin resistance with relative insulin deficiency to secretory deficit with insulin resistance

Diabetic Ketoacidosis (DKA)

Absolute lack of insulin → release of counterregulatory hormones → lipolysis → ketone production → metabolic acidosis

DKA counterregulatory hormones

Cortisol and glucagon

DKA key findings

- Hyperglycemia (above 250mg/dL)

- Ketones present

- Metabolic acidosis (low bicarb)

- Fruity breath

- Kussmaul Respirations (rapid and deep)

DKA is common with patients who have ...

Type 1 diabetes

Hyperosmolar Hyperglycemia Syndrome (HHS)

Lack of adequate insulin → hyperglycemia → osmotic diuresis → dehydration

HHS key findings

- Severe hyperglycemia (>600mg/dL)

- High serum osmolality

- Normal pH (no ketones)

- Polyuria (glycosuria → osmotic diuresis)

DKA summary of findings

- Found in T1DM

- Rapid (hours) onset

- Glucose >250mg/dL

- Ketones present in large amounts

- Metabolic acidosis present

- Mild increase in osmolality

- Alert to stupor mental status

HHS summary of findings

- Found in T2DM

- Gradual (days) onset

- Glucose >600mg/dL

- Ketones minimal or absent

- Metabolic acidosis NOT present

- Severe increase in osmolality (>320)

- Confusion to coma mental status

DKA clinical manifestations

- Polyuria/polydipsia

- Fruity breath

- Kussmaul respirations

- Nausea/vomiting

HHS clinical manifestations

- Severe dehydration

- Altered mental status

- Hypotension/tachycardia

- Seizures (in extreme cases)

DKA/HHS labs to review

- Blood glucose

- ABGs

- CMP (Na, K, BUN, Cr)

- CBC with diff

- Serum osmolality

- UA (ketones/glucose)

- ECG

DKA/HHS treatment

Fluid Replacement

- Isotonic saline (0.9%NS)

- Switch to D5W when glucose ~200-250 mg/dL

Insulin Therapy

- IV regular insulin

- Titrate based on hourly glucose

Electrolyte Monitoring

- Potassium: replace as needed

- Monitor for hypo/hyperkalemia!

Identify & Treat Underlying Cause

- What can cause HHS or DKA?

Nursing priorities with DKA/HHS

- Monitor vitals & LOC

- Strict I&O

- Hourly glucose checks

- Watch for signs of cerebral edema

- Cardiac monitoring (K+)

- Patient/family education post-crisis