DKA & HHS

DKA Labs

Usually type 1

Rapid onset

>250 glucose

<7.3 pH

Present ketones

<15 bicarb

Elevated kidney labs

HHS Labs

Slower (several days)

>600 glucose

normal pH

Absent ketones

Normal bicarb

Elevated kidney labs

DKA rf

13-25 age

female

previos episodes

HHS rf

Older than 65

african american

native american

hispanic

morbid obesity

DKA impact on health

• Metabolic acidosis 

• Muscle weakness

• Dehydration leading to decreased cardiac output

• Loss of electrolytes 

  • Cardiac arrhythmias

  • High POtassium initially

• Kussmaul respirations

• Decreased perfusion to kidneys

HHS impact on health

• More profound neurological manifestations

• Muscle weakness

• Profound dehydration

• Thromboembolic disease (clot risk)

• Decreased perfusion to the kidneys

• Loss of electrolytes

  • Cardiac arrhythmias

DKA + HHS Presentation

• Decreased level of consciousness: fatigue, lethargy, coma

• Nausea and vomiting

• Abdominal pain

• Fruity breath odor (DKA)

• Hyperventilation

• Hypotension

• Arrhythmias

• Blurred vision

• Polydipsia

• Weight loss

• Hypokalemic

Labs and diagnostic studies

• Serum blood glucose: DKA greater than 250mg/dL and HHS greater than 600 mg/dL

• Complete blood count: assess WBC

• Electrolytes: K, MG, NA, Cl, Phos, 

• ABGs: clients in DKA will be in metabolic acidosis pH less than 7.3 and HCO3less than 15

• Anion gap: DKA greater than 10 mEq/L indicating acidosis. HHS: within normal limits

• Serum osmolality: HHS greater than 320 mOsm/kg

• Urine studies: UA, Ketones, Urine culture: DKA will have both glucose and ketones present. Urine osmolality will be above expected range in DKA.

• Chest X-Ray: determine presence of respiratory illness (pneumonia)

• ECG: assess for dysrhythmias 

• Blood and Urine Cultures: looking for sepsis

DKA and HSS treatment

Circulatory volume

• Large bore IV or central line

• Replace half of the deficit in 12-24hrs

• IV Isotonic fluid to increase intravascular volume

• monitor sodium

• switch to IV hypotonic

• BG <250 in DKA, <250 in HHS, → switch fluid to D5 in 0.45% NS

Treat hyperglycemia

• Avoid a rapid drop in blood glucose levels

• Bolus of IV regular insulin based on client’s weight (0.1 units/kg)

• Continuous IV regular insulin at 0.1 units/kg/hour

• Goal is to decrease blood glucose by 50 to 70 mg/dL/hr (adjust rate if this is not met)

• Once blood glucose is consistently less than 200 mg/dL for DKA and less than 300 mg/dL for HHS IV insulin rate can be decreased to 0.02-0.05 units/kg/hour.

• Adjust rate hourly to keep blood glucose of 150 to 200 mg/dL

• Once DKA or HHS is resolved and client tolerates oral intake, transition to SQ insulin (dose will vary depending on client’s history)

• IV insulin continued for at least 2 hours after the first dose of SQ insulin

Correct electrolyte ibalance

• Potassium: 4.0-5.0

• Sodium: correct with fluids

• Magnesium as needed

Sick day rules

Insulin drip and IV push

need a 2nd nurse to verify the order

discard first 50ml of fluid