16 Questions
What is the approximate mortality rate associated with a single episode of DKA?
5%
What is the primary cause of death in patients with DKA?
Underlying precipitating illness
Which type of diabetes is DKA most commonly associated with?
Type 1 diabetes
What is the minimum blood glucose level required for diagnosis of DKA?
11.1 mmol/L
What is the primary difference between DKA and HHS in terms of pathogenesis?
Duration of hyperglycaemia
What is the common finding in patients with HHS?
Hypernatraemia
What is the estimated fluid loss in a person weighing 100 kg with HHS?
10-22 L
What is the mortality rate associated with HHS?
20%
Why do people with HHS not develop significant ketoacidosis?
Their insulin levels are sufficient to prevent lipolysis and subsequent ketogenesis
What is a common precipitating factor for HHS?
Infection, such as pneumonia or urinary tract infection
What is a poor prognostic sign for HHS?
Hypotension
What is a key goal of managing HHS?
To normalize osmolality and blood glucose
Why should fluid replacement be less aggressive in HHS?
To avoid precipitating cardiac failure in patients with coronary artery disease
What is a concern in older patients with HHS?
Delirium
How should the rate of glucose lowering be guided in HHS?
By serial calculations of serum osmolality and glucose
Why is a slower approach to correction of electrolyte and metabolic abnormalities preferred in HHS?
Because there is no urgent need to correct ketoacidosis
Study Notes
Diabetic Ketoacidosis (DKA)
- Acute metabolic complication of diabetes resulting from absolute insulin deficiency, and a medical emergency with important complications
- Mortality rates have fallen in the UK, but a single episode is associated with a 5% risk of death, rising to 25% in recurrent cases
- Most commonly occurs in people with type 1 diabetes, but can also occur in type 2 diabetes, particularly in those with significant β-cell dysfunction
Diagnosis of DKA
- Hyperglycaemia (blood glucose >11.1 mmol/L or 200 mg/dL)
- Hyperketonemia (≥3.0 mmol/L on fingerprick testing) or ketonuria (more than 2+ on urine dipstick testing)
- Metabolic acidosis (venous bicarbonate <15 mmol/L or pH <7.3)
Hyperosmolar Hyperglycemic State (HHS)
- Associated with a higher mortality rate (up to 20%) due to age and frailty of the population
- Pathogenesis is incompletely understood
- Caused by an osmotic diuresis, leading to dehydration and hypernatraemia
- Fluid loss can be substantial (10-22 L in a person weighing 100 kg)
- Reason for lack of significant ketoacidosis is unclear, possibly due to insulin levels sufficient to prevent lipolysis and ketogenesis
Precipitating Factors and Prognosis of HHS
- Common precipitating factors: infection, acute illness, drug therapy, and postoperative hospitalization
- Poor prognostic signs: hypothermia, hypotension, serum osmolality >360 mOsmol/kg, and multiple comorbidities
Management of HHS
- Aims: normalize osmolality and blood glucose, replace fluid and electrolyte losses, and prevent complications
- Slower approach to correction of metabolic abnormalities recommended, avoiding rapid shifts in osmolality
- Co-morbidities must be taken into account, such as cardiac failure and delirium
Test your knowledge of Diabetic Ketoacidosis, a medical emergency and acute metabolic complication of diabetes, its diagnosis, and risks.
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