Acute metabolic complications of diabetes mellitus:
- DKA is characterized by ketosis, acidosis, and hyperglycaemia. It is more common in type 1 diabetes.
- HHS is characterized by hyperglycaemia, severe dehydration and hypovolemia, but no ketosis and acidosis.
It is more common in type 2 diabetes.
Causes
- Newly diagnosed diabetes
- Poor control of diabetes mellitus
- Treatment interruptions
- Infections and trauma
Clinical features
DKA
- Acute onset (24 hours or less)
- May be preceded by the typical symptoms of excessive thirst, fluid intake, and passing of urine, weight loss,
tiredness - Abdominal pain, vomiting
- Alterated consciousness, coma
- Deep breathing (acidotic)
- Sweet, acetone smell on the breath (from ketosis)
- Cardiovascular collapse (hypotension)
HHS
- Slower onset
- More severe dehydration and fluid deficit
- No ketosis and acidosis (no/few ketones in urine)
Differential diagnosis
- Other causes of ketoacidosis/hyperglycaemia
- Other causes of acute abdominal pain
- Other causes of coma
Investigations
- Blood sugar
- Urine analysis (for ketones, positive)
- Full blood count
- Renal function and electrolytes (Na, K)
Management
General measures
- Monitor BP, urine output, and blood sugar hourly
- Urinary catheter if uncoscious
- Treat infections if present (they can be a precipitating factor)
- Enoxaparin 4000 IU SC until patient is able to move (to prevent thromboembolism)
- Normal saline (NaCl 0.9%)
- 15-20 ml/kg in the first hour (500-1000 ml) Children: 10-20 ml/kg
- Continue with 5-15 ml/kg/hour according to vital signs, urinary output, and clinical condition
- If blood sugar <14 mmol/L, switch to dextrose 5% if ketones still present, and/or clinical condition
not yet normal (patient unable to eat) - Soluble insulin 4-6 IU IM every hour until condition stabilises
Child >5 years: 0.1 IU/kg/hour
Child <5 years: 0.05 IU/Kg/hour- Continue insulin until ketosis resolves, and patient is able to eat
- Once clinical condition normalises (normal BP, consciousness, urine output, and able to eat), start
Insulin SC regimen (see previous section) 1-2 hours before stopping the IM insulin
Potassium (KCl)
If potassium level not available
- Add potassium chloride 1 ampoule in every 1 litre of infusion as soon as the patient has
started passing urine
If potassium levels available:
- K <3.5 mmol/L: add 40 mmol (2 ampoules) per 1 litre of fluid
- K 3.5-5.5 mmol/L: add 20 mmol (1 ampoule) per 1 litre of infusion
- K >5.5 mmol/L: do not add any potassium
Prevention
- Early detection
- Good control of diabetes
- Prompt treatment of infections
- General education