DKA & Hyperosmolar hyperglycemia state

• DKA often occurs in younger patients. the patient maybe vomiting, having abdominal pain and have acidotic breathing
• DKA is associated with: 1)blood glucose <40mmol/L 2)blood ketones positive 3)serum osmolality <350 mOsm/L
• HHS is a syndrome characterised by impaired consciousness,seizures,dehydration and severe hyperglycemia with negative ketoacid. (pH is usually >7.2)
• HHS usually occurs in elderly type 2 diabetics. and usually associated with:1) blood glucose>40mmol/L 2)blood ketones negative or moderately increased 3)urine ketones may be positibe 4)serum osmolality >320 mOsm/L
• General measures include: setting up an IV line, insert nasogastric tube to keep airway open if they are unconscious,check their urine output,check their plasma glucose-ketone-electrolytes and blood gas,look for their precipitating causes e.g infection or MI
• Medicine treatment: Give fluids, in the absence of renal failure or cardiac problems give sodium chloride 0.9%,IV,15-20 mL/kg in the first hour then the following infusion rate of NaCl will be 5-15mL/kg/hour depending on their response
• we give fluids for atleast 24hours and the volume of infusion given in the first 4hours should not be more than 50mL/kg
• reduction of serum osmolality should not be more than 3mOsm/kg/hour
• if the patient sodium plasma is >140 mmol/L give sodium chloride 0.45%,IV. if the patient sodium plasma is 140 mmol/L or less then give sodium chloride 0.9%, IV
• if plasma glucose is <15mmol/L,but ketones still present the give dextrose 5% OR give dextrose 10% in sodium chloride 0.9%,IV
• be aware that cerebral edema may occur when we overly give fluids
• do check potassium levels and do potassium replacement in DKA patients because remember insulin treatment drop potassium levels so they need potassium replacement
• 1 ampoule=20mmol=10mL
• So give Potassium Chloride,IV,added to 1L of fluid. if patient potassium is <3.5mmol/L give 40mmol of potassium chloride. if potassium is between 3.5-5.5mmol/L add 20mmol/L to 1L. then if potassium is >5.5mmol/L do not add potassim chloride to patient therapy. max dose of potassium-40mmol/hour
• so combined insulin+ glucose + potassium is needed to be given in DKA patient to ensure clearance of ketones in blood
• insulin therapy include: 1)insulin,short-acting,IV infusion,50 units in 200mL sodium chloride 0.9%. -4mL=1unit 2)initial infusion is 0,1 units/kg/hour then after that give 5-7 units/hour which is 20-28mL/hour. if plasma glucose does not drop by 3mmol/L in first hour, then double dose
• if IV infusion cannot be used,then we need to administer intramuscularly-bolus injections. give insulin short-acting 100units with sodium chloride 0.9% to 10mL-10units/1mL. initial dose 0.5units/kg-give patient half dose as IV bolus injection and half IM. then after that give 5-10 units IM
• for all patients give heparin LMWH,enoxaparin,SC,40mg daily OR give unfractionated heparin,SC,5000 units 12hourly