DIABETIC KETOACIDOSIS AND HYPEROSMOLAR HYPERGYLCAEMIC STATE

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