2025 – PAGE 88 – ENDOCRINOLOGY
DIABETIC KETOACIDOSIS (DKA) AND HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)
DIABETIC KETOACIDOSIS or HYPEROSMOLAR HYPERGLYCEMIC STATE = DKA or HHS = Replace fluid over 36–48 HOURS, NOT over 24 hours because of the risk for cerebral edema related to rapid osmolar shifts. If the patient has a low sodium level, it’s probably PSEUDOHYPONATREMIA and does NOT need hypertonic saline. Start with NS boluses. DKA = K+ deficit. Give up to 60 mEq/L of potassium if the K+ is low. Add glucose to IV fluids once blood glucose (BS) is < 300. DON’T give bicarbonate because there are only rare indications for it (pH < 7.1). Patients with HHS usually have type 2 diabetes and they are usually extremely dehydrated. Type 2 diabetics produce insulin, utilize some glucose for energy, and thus they have minimal acidosis and rarely require early insulin administration. HHS can usually be treated with IV hydration alone. DKA patients require insulin, hydration and potassium replacement.
PEARL:
| DKA | HHS |
| Typically occurs in T1DM | Typically occurs in T2DM |
| Bicarbonate < 18 (usually < 15) | Bicarbonate > 15 |
| pH < 7.3 | |
| ++Ketones in the serum and urine | Urine and serum ketones are usually minimal or absent. |
| Glucose usually 250 – 500 | Glucose usually > 600 |
| Neurological status varies from alert to being in a coma depending on if it’s mild or severe | Neurologic changes (stupor, coma, seizures, etc.) are very common |
| Serum osmolality is variable, but usually < 320 | Serum osmolality is usually > 320 |
| Treatment includes insulin + hydration + potassium | Main treatment is IV hydration. Minimal ketosis means minimal (or no) need for early insulin. |
TYPE 2 DIABETES MELLITUS (T2DM)
To diagnose type 2 diabetes mellitus (T2DM), the patient must have at least two abnormal tests. Acceptable tests include an HbA1C > 6.5, a random plasma glucose > 200, a fasting glucose > 126 (on two separate occasions, plus symptoms) and a 2-hour OGTT > 200. To help differentiate between TIDM and T2DM, look at the BMI, family history and evidence of acanthosis nigricans.
PEARL: A low C-peptide level and positive T1DM antibodies are consistent with T1DM. A high C-peptide level and negative T1DM antibodies are consistent with T2DM.