dka + hhs

what can trigger HHS and DKA?

- infections

- inadequate or noncompliance with insulin treatment

- acute illness

- medications

- drugs - alcohol and cocaine

which medications can trigger HHS and DKA?

- corticosteroids

- olanzapine (antipsychotic)

- lithium (used to reduce blood glucose levels)

- clozapine (antipsychotic)

what can trigger HHS specifically?

- dehydration

- BBs

- diuretics

- CCBs

- endocrine disorders (cushings, acromegaly, thyrotoxicosis)

what can trigger DKA specifically?

- new onset diabetes

- SGLT2 inhibitors

what are the symptoms of DKA? (6)

RAPID ONSET (over 24 hrs)

- polyuria

- polydypsia

- n + v

- abdominal pain

- weakness

- weight loss history

what are the signs of DKA?

- tachycardia

- hypotension

- hypothermia

- kussmaul respirations (compensatory hyperventilation)

- fruity breath

- signs of severe dehydration

what causes fruity breath?

exhaled acetone

what are the signs of severe dehydration? (5)

- dry mucous membranes

- sunken eyes

- decreased skin turgor

- anhidrosis

- decrease urine output

what is anhidrosis?

inability to sweat

what are the symptoms of hhs?

GRADUAL DEVELOPMENT (days to weeks)

- polyuria

- polydypsia

- n + v

- neurologic changes

what are the possible neurologic changes? (6)

- lethargy

- delirium

- coma

- seizures

- sensory deficits

- vision changes

what are the signs of hhs?

- tachycardia

- hypotension

- hypothermia

- NOT kussmaul breathing usually

- signs of dehydration

- altered mental status

- hemiparesis - paralysis on one side of body

- hemianopia - vision loss of one half of vertical visual field

what do the hormone abnormalities lead to?

hyperglycaemia

what are the hormone abnormalities in dka? (5)

- insulin deficiency

- increased glucagon

- increased cortisol

- increased growth hormone

- increased catecholamines

how do the hormone abnormalities lead to hyperglycaemia? (5)

- increased gluconeogenesis

- increased glycogenolysis

- decreased glycolysis

- increased amino acid delivery from muscle

- increased glycerol delivery from adipose tissue

what does severe hyperglycaemia lead to?

- increased osmolality => draws water out of cells => dilutes sodium conc

- glucosuria => osmotic diuresis

what does osmotic diuresis lead to? (4)

- water and electrolyte loss (sodium + potassium)

- dehydration

- increased osmolality

- impaired renal function

how does ketoacidosis occur?

1) increased lipolysis

2) increased free fatty acids

3) increased ketone production (ketogenesis)

does dka have a raised or normal anion gap?

raised

how is the anion gap raised?

decreased bicarbonate => consumed as a buffer => increased anion gap

what happens in terms of potassium in dka?

1) potassium shifts out of cells

2) increased extracellular potassium

3) decreased intracellular potassium

4) potassium excreted in urine

5) decreased total body potassium - hypokalaemia

what are the levels of sodium in dka?

hyponatraemic

what is a rare but serious complication of dka?

cerebral oedema

what is hhs?

hyperosmolar hyperglycaemic state

what is hhs also referred to as?

hyperglycaemic hyperosmotic nonketotic coma - HONK

what are the hormone abnormalities in hhs?

- decreased insulin or insulin resistance

- increased glucagon

- increased cortisol

- increased growth hormone

- increased catecholamines

what are two differences between hhs and dka?

- no acidosis in hhs

- more severe hyperglycaemia in hhs

why is there no acidosis in hhs?

some insulin is present, so ketogenesis is prevented

what are the sodium and postassium levels in hhs?

- hyponatraemia

- hypokalaemia

(bc it is still hyperosmolar)

what is the acronym for management of dka?

FIGPICK

what does FIGPICK stand for?

Fluids - IV with normal saline (0.9%) + potassium

Insulin - actrapid at 0.1 unit/kg/hr

Glucose - monitor levels and add dextrose if low

Potassium - monitor levels every 4 hrs and correct

Infection - treat triggers such as infection

Chart - chart fluid balance

Ketones - monitor levels/ bicarb levels if ketones not possible

what happens if the ketosis and acidosis has not resolved in 24 hours?

review by endocrinologist

what is the difference in management of hhs?

- lower rates of insulin infusion

- slower rehydration