DKA and HHS

DKA and HHS

what are the acute complications of insulin metabolism

DKA

profound deficiency of insulin that is characterized by hyperglycemia, ketosis, acidosis, and dehydration that is most likely to occur in those with type 1 DM, but can occur in those with type 2

• illness

• infection

• inadequate insulin dosage

• undiagnosed type 1 DM

• poor self management

• neglect

• severe illness, infection, stress

what are RF/triggers for DKA

• glucose can’t be used for energy so the body breaks down fat forming ketones as a byproduct 

  • acidosis (low pH)

  • ketonuria

• insulin deficiency…

  • impairs protein synthesis and causes excessive protein degradation and nitrogen losses from the tissues

  • stimulates production of glucose from proteins in the liver and leads to future hyperglycemia

  • additionally glucose cannot be used so BG rises more adding to the osmotic diuresis

  • depletion of sodium, potassium, chloride, magnesium, and phosphate

  • hypovolemia, shock, comatose, renal failure

• dehydration: poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension

• lethargy and weakness

• skin is dry and loose and eyes become soft and sunken

• abdominal pain, anorexia, N/V

• Kussmaul respirations, acetone on breath

• BG > 250

• ph < 7.30

• HCO3 < 16

• moderate/high ketones in urine

what are the s/s of DKA

• ensure patent airway, administer O2 via NC or nonrebreather

• establish IV access and begin fluid and electrolyte replacement

  • 0.45 or 0.9% NS at a rate to restore urine output to 30-60 mL/hr and raise BP

  • When BG levels approach 250 mg/dL, add 5-10% dextrose to the fluid to prevent hypoglycemia nd a sudden drop, which can be associated with cerebral edema

  • monitor those with renal/cardiac issues for fluid overload

• measure potassium before starting insulin

  • if hypokalemic, insulin will make it worse and can cause life threatening dysrhythmias

• insulin via continuous IV at 0.1 u/kg/hr

• monitor fluid balance and potassium levels

• must be on continuous ECG monitoring

what does treatment for DKA include

HHS

a life threatening syndrome that can occur in the patient with DM who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and EC fluid depletion; most often occurs in patients older than 60 with type 2 DM and is often related to impaired thirst sensation and/or a functional inability to replace fluid

• impaired thirst sensation

• functional inability to replace fluids

• inadequate fluid intake

• mental depression

• polyuria

• UTIs

• pneumonia

• sepsis

• acute illness

• newly diagnosed T2 DM

what are causes/RF/triggers for HHS

• fluid volume deficiency causes low sodium, potassium and phosphorus

• electrolyte imbalances causes profound dehydration, hyperosmolality, and hypovolemia

• hypovolemia causes…

  • decreased renal perfusion, oliguria, anuria

  • hypotension, tissue anoxia, increased lactic acid

  • hemoconcentration, hyperviscosity, thrombosis

• does have ENOUGH circulating insulin that ketoacidosis does not occur

• produces fewer S/S in the earlier stages so BG levels climb quite high before the problem is recognized

• higher BG levels increase serum osmolality and cause more severe neuro effects

  • somnolence, coma, seizures, hemiparesis, aphasia

• BG > 600

• increase in serum osmolality

• Ketones absent/minimal in blood and urine

what are the S/S of HHS

• immediate IV admin of insulin 0.45 or 0.9% NS

• usually needs more volumes of fluid replacement slowly and carefully

• hemodynamic monitoring to avoid fluid overload

• dextrose is added to IV fluids when BG levels fall to 250

• monitor electrolytes

• once stable detect and correct the underlying cause

what are the treatments for HHS

• IV fluids

• insulin therapy

• replace and monitor electrolytes

• monitor BG

• assess renal status, cardiopulmonary status, and LOC

• assess for signs of potassium imbalance

• cardiac monitoring to detect hyper/hypokalemia

• assess VS to determine the presence of fever, hypovolemic shock, tachycardia, and Kussmaul respirations

what are the similarities for treatment of both DKA and HHS