Diabetic Hyperglycemic Emergencies: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)

Diabetic Hyperglycemic Emergencies: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)

1. Introduction

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two dangerous acute complications of diabetes mellitus (DM) that can lead to death if not treated promptly.

2. Basic Concepts

• DKA (Diabetic Ketoacidosis): Ketoacidosis due to insulin deficiency, increased glucose production in the liver, and decreased glucose uptake in tissues, leading to hyperglycemia.

• HHS (Hyperosmolar Hyperglycemic State): Hyperosmolarity due to very high blood glucose, leading to severe dehydration and electrolyte disturbances.

3. Epidemiology

• DKA: Incidence of 4.6-8/1000 people/year, more common in type 1 DM than type 2 DM. Often presents at the time of DM diagnosis. Mortality rate is 2-5%.

• HHS: Incidence of 0.6-1/1000 people/year, seen in type 2 DM, especially in older adults with co-morbidities. Mortality rate is 12-24%.

4. Pathophysiology

• DKA: Insulin deficiency leads to increased glucose production in the liver, decreased glucose uptake in tissues -> hyperglycemia. Fat breakdown -> ketone body formation -> ketoacidosis + metabolic acidosis.

• HHS: Insulin deficiency -> Glycogenolysis, gluconeogenesis -> hyperglycemia. Osmotic diuresis -> severe dehydration -> hyperosmolarity.

5. Symptoms

• DKA:

• Hyperglycemia: Polydipsia, polyphagia, weight loss, polyuria, dehydration (dry mucous membranes, tachycardia, hypotension, flat neck veins, decreased urine output), shock.

• Ketoacidosis: Fatigue, anorexia, nausea, abdominal pain.

• Metabolic acidosis: Kussmaul breathing, altered mental status.

• HHS:

• Very high blood glucose: > 600 mg/dl.

• Severe dehydration: Dry mucous membranes, tachycardia, hypotension, flat neck veins.

• Altered mental status: Confusion, coma.

• Electrolyte disturbances: Abnormal potassium, sodium, phosphate.

6. Predisposing Factors

• DKA:

• Type 1 & 2 DM.

• Relative insulin deficiency (due to trauma, infection, surgery, cancer, acute medical illness).

• Absolute insulin deficiency (insulin cessation, newly diagnosed DM).

• HHS:

• Acute medical illness, injury, medication.

7. Coma Progression

• DKA: Often has hyperglycemic symptoms. Coma occurs within a few hours to a day.

• HHS: Slower progression, may take days to weeks.

8. Triggering Factors

• DKA: Relative or absolute insulin deficiency, insulin cessation, newly diagnosed DM, infection, acute medical illness.

• HHS: Uncontrolled type 2 DM, infection, trauma, surgery.

9. Diagnosis

• DKA:

• Clinical presentation: Polydipsia, polyuria, dehydration, epigastric pain, nausea, abdominal pain, Kussmaul breathing, altered mental status.

• Laboratory tests: Blood glucose > 16.6 mmol/L, increased blood ketones, acidosis.

• HHS:

• Blood glucose > 600 mg/dl, serum osmolality > 320 mOsmol/kg, negative or mildly positive ketones.

• Normal or elevated serum sodium, abnormal potassium.

• Electrolyte disturbances, hemoconcentration, increased urea, hematocrit, increased serum protein.

10. Treatment

• DKA & HHS:

• Fluid resuscitation: 0.9% NaCl, enough fluid to replace 50% of lost water in the first 4-6 hours.

• Insulin:

• DKA: Rapid-acting insulin, intravenous infusion at 0.1-0.15 U/kg/h, then adjust dose based on response.

• HHS: Lower insulin dose than DKA, intravenous infusion at 3-7 U/h.

• Electrolyte correction: Monitor and supplement potassium, sodium, phosphate, and magnesium as needed.

• Coexisting medical conditions: Treat any other medical conditions.

11. Complications

• DKA:

• Non-treatment related: Hypovolemic shock, lactic acidosis, renal failure, thrombosis, infection.

• Treatment related: Pulmonary edema, hypoglycemia, hypokalemia, cerebral edema, recurrent ketoacidosis.

• HHS:

• Treatment related: Hypoglycemia, hypokalemia, cerebral edema.

12. Mortality

• DKA: Hypokalemia, myocardial infarction, pulmonary embolism.

• HHS: Cerebral edema.

• Common: Severe acidosis, severe underlying medical illness.

13. Post-discharge Education

• Monitor blood glucose regularly, follow-up appointments.

• Recognize signs and symptoms of complications, seek medical attention promptly when necessary.

14. Note

• DKA and HHS are dangerous acute complications of DM, requiring timely treatment to avoid severe complications and death.

• Closely monitor and care for the patient throughout the treatment process.

• Educate the patient about DM knowledge and self-care to prevent complications.

15. References

• Textbook of Internal Medicine – Ministry of Health

• Guidelines for the Diagnosis and Treatment of DM – Ministry of Health

Note: This article is for informational purposes only and should not be a substitute for medical advice.