DKA, HHS and Diabetes Care
Hyperglycemic crises (2024 ADA/EASD consensus) and long-term care
DKA vs. HHS
| Diabetic ketoacidosis (DKA) | Hyperosmolar hyperglycemic state (HHS) | |
|---|---|---|
| Who | Mostly type 1; any age; onset hours | Mostly type 2, older adults; onset over days |
| Glucose | ≥200 mg/dL (or known diabetes; can be near-normal with SGLT2 inhibitors) | ≥600 mg/dL |
| Acid–base | pH <7.3 and/or HCO₃⁻ <18 | pH ≥7.3, HCO₃⁻ ≥15 |
| Ketones | High (β-hydroxybutyrate ≥3.0 mmol/L) | Minimal |
| Signs | Kussmaul breathing, fruity breath, abdominal pain, vomiting, dehydration | Severe dehydration, osmolality >300, confusion, seizures, coma |
In DKA, glucose is stuck in the blood: cells can't use it without insulin, so the body burns fat and makes ketones. Common triggers: infection, missed insulin, new diagnosis.
Treatment order
- Fluids first: isotonic (0.9% saline or balanced crystalloid), about 500–1,000 mL/h for the first 2–4 h (smaller boluses in older adults or heart or kidney failure), then adjust.
- Check potassium before insulin. K⁺ <3.5 → replace K⁺ before starting insulin. 3.5–5.0 → add K⁺ to fluids. >5.0 → no K⁺, recheck often.
- Insulin: IV regular insulin infusion (or SC rapid-acting in mild–moderate DKA).
- Add dextrose (5–10%) when glucose falls below ~250 mg/dL, and keep insulin running until the crisis resolves.
- Bicarbonate only if pH <7.0.
- Resolved (DKA): pH ≥7.3, HCO₃⁻ ≥18, ketones low. Give SC basal insulin 1–2 h before stopping the drip.
Monitor
- Glucose every hour; K⁺, Na⁺, phosphate every 2–4 h.
- Cardiac monitor (K⁺ shifts into cells with insulin → hypokalemia).
- Urine output, mental status. Children: cerebral edema (headache, falling LOC): correct slowly.
Long-term diabetes care
- A1C every 3–6 months; dilated eye exam yearly; urine albumin and eGFR yearly; BP and lipids.
- Foot care: inspect daily (mirror), wash and dry well (especially between the toes), moisturize but not between the toes, well-fitting shoes, never barefoot, no heating pads or hot soaks, podiatry for nails if neuropathy.
- Exercise: check glucose first; carry fast carbs; delay exercise if glucose >250 with ketones.
- Continuous glucose monitors are widely used: know how to read trend arrows.
Priority
A diabetic patient who is confused, sweaty and shaky: check glucose. If you can't check quickly and the patient is symptomatic, treat as hypoglycemia: low glucose kills faster than high glucose.