Is it DKA or HHS

8/10/2019 Is it DKA or HHS

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5 Is it DKA or HHS?

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His vital signs are temperature 102.4 F, respirations

22 breaths/minute, pulse 110 beats/minute, andblood pressure 90/60 mm Hg. He has dry mucous membranes,

poor skin turgor, and bilateral wheezing in both

lungs. A fingerstick blood glucose level reads high on

the meter, indicating a value above 600 mg/dl.

Mr. Suarezs wife states that she called 911 after finding

her husband lying in the bedroom unresponsive. She

says he has a history of hypertension, for which hes taking

chlorothiazide (a thiazide diuretic), and hyperlipidemia,

which he controls with atorvastatin. Two days

ago, he finished a 5-day course of antibiotics prescribed

for bronchitis. She also says her husband has been drinking

fluidsand urinatingmore frequently than usual.STAT laboratory tests show a plasma glucose level of

1,050 mg/dl, plasma osmolarity above 320 mOsm/kg,

serum sodium level below 120 mEq/L, serum potassium

level of 4.0 mEq/l, arterial pH 7.45, and a white blood cell

(WBC) count of 30,000/mm3. Plasma ketones are absent

Although Mrs. Suarez says her husband has never

been diagnosed with diabetes mellitus, his extremely

high blood glucose level certainly suggests he has diabetes.

Based on his other assessment findings, youd be

correct to assume hes experiencing an acute complication

of diabetes. But which one?

Is it DKA or HHS?

Test DKA HHSUrine or plasma ketones Always present Absent or minimalBlood pH Low NormalPlasma osmolarity Normal HighGI findings (nausea, vomiting) Common Absent
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DKA

DKA results from uncontrolled hyperglycemia

associated with type 1 diabetes

In DKA,

extreme hyperglycemia leadsto lipolysis, which induces a

ketotic and acidotic state.

DKA occurs when there is not enoughinsulinin the body, resulting in high blood glucose; the person

is dehydrated; and too manyketonesare present in the bloodstream, making it acidic. The initial

insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not

taking insulin when it is needed.

Ketones are your brains second-best fuel, Hellman says, with glucose being number one. If you

dont haveenough glucose in your cells to supply energy to your brain, your body breaks fat down

into small pieces so that it can be used as fuel. Ketones are formed during that process. Everybody

has ketones in their bloodstream at some point, even people who don t have diabetes. Your bodysometimes uses them for fuel when you restrict your food intake, when you havent eaten for a while

even overnight, in very tiny amounts and when youexercise.

The problem comes when you have diabetes and lack sufficient insulin to move glucose from your

bloodstream into your bodys cells. Your body believes it isnt getting enough food, so it reacts in two

ways: It instructs the liver to turnglycogen(stored glucose) into glucose and release it into the

bloodstream, and it begins to use fat for energy. The higher your blood glucose rises, the more fat is

used and the more ketones are formed.

When you run out of insulin, ketone production becomes excessive, Hellman says. It takes

approximately two hours after you run out of insulin for excessive ketone accumulation to occur.

Ketones accumulate in your blood and, from there, go into the urine. That causes excessive

urination, which is added to the increased urine production from high blood glucose. You then begin

to become dehydrated.

At the same time, the increase in ketone production begins to change your bodys chemistry, and it

becomes more acidic. The increased acidity changes the delicate mechanisms that regulate your

body changes that can affect yourheartand, perhaps, your brain. In addition to urinating more,

your body also tries to get rid of the excess acid by exhaling it, so your breathing becomes shallow

and rapid and smells like acetone, or fingernail polish remover. Badly needed fluids may not be

retained because of vomiting. Because your body isnt getting the food it needs for energy, you

have an overwhelming feeling of sleepiness. And you experience abdominal pain. In fact, Dr.Hellman says, DKA is sometimes misdiagnosed as appendicitis.

The treatment can be as simple as restoring fluids and insulin to the body, or as complicated as

doing that plus bringing the bodys chemistry back into balance,

Signs and SymptomsReturn to Article
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SUPPLEMENTARY CONTENT

Unexplained blood glucose level higher than 250 mg/dl

Presence of ketones in blood or urine

Fruity smelling breath

Dry mouth Nausea

Vomiting

Fever

Abdominal pain

Low blood pressure

Shortness of breath

Dehydration

Increased heart rate

Pale or clammy skin

Coma

HHSHHS, on the other hand,

stems from uncontrolled hyperglycemia associated withtype 2 diabetes. Ketosis (blood and urine) is absent even

with severe hyperglycemia. HHS because

of its slow onset and insidious signs and symptoms. Usually age 60 or older.

With Type 2 diabetes growing the incidence of HHS is rising dramatically, you can expect the incidence

of HHS to rise, too.

HHS classic findingssevere hyperglycemia without ketosis,

high plasma osmolarity, normal pH, a recent history

of infection, and current diuretic therapy

In HHS, hyperglycemia causes polyuria-induced dehydration

and induces cortisol and glucagon release.

Dehydration, in turn, triggers movement of intracellular

fluids out of cells. Combined with dehydration, cortisol

and glucagon release exacerbates hyperglycemia. Intracellular

fluid depletion further destabilizes metabolic

homeostasis; as a result, sodium, potassium, and magnesium

are lost to diuresis.

Polyuria occurs when the kidney reaches its glucose

thresholdthe level that triggers frequent urination as a

means of glucose removal. Generally, plasma glucose activates


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the kidneys excretory response at levels of 180 to

250 mg/dl. However, the protective effect of glucose removal

from the body eventually disappears as fluid volume

is depleted and the kidneys become less effective at

excreting glucose. The degree of osmolarity determines

alterations in consciousness and the morbidity risk

Risk factors that PREdispose patients to HHSFactors that predispose a patient to HHS include:

type 2 diabetes with uncontrolled hyperglycemia

decreased fluid intake

underlying illness

infection (present in 60% of cases)

stressors

certain drugs, such as steroids, diuretics, and beta

blockers

history of myocardial infarction, thrombosis, compromised

renal function, or dialysis

age above 60 (especially in patients in hospitals and

long-term care facilities).

Suspect HHS in a patient with type 2 diabetes who

has severe hyperglycemia, polyuria, polydipsia, profound

dehydration, weakness, altered mental state or

neurologic changes, or stroke-like symptoms. But keep

in mind that some patients, have no

known history of diabetes.

Laboratory findings typical of HHS include:

plasma glucose level above 600 mg/dl

blood urea nitrogen above 30 mEq/dl

plasma osmolarity above 320 mOsm/kg

abnormal electrolyte levels

blood pH above 7.3

minimal to absent ketones.Blood and urine cultures should be obtained to determine

if the patient has an underlying medical condition

that might have triggered HHS.

Assessment findingsOnset of HHS occurs over 12 days, on average. If misdiagnosed,

the patient may suffer a serious medical

emergencyby the time its correctly diagnosed

Acute managementAcute management of HHS involves prompt fluid and electrolyte replacement and insulin administration. The

goal of fluid replacement is to increase circulatory volume

and restore intracellular fluids. Typically, normalsaline solution is given; once the patient is rehydrated,

some clinicians administer half-normal saline solution

with regular insulin added proper treatment means admission to

the intensive care unit to correct hyperglycemia, severe

dehydration, and electrolyte imbalances. His unresolved

bronchial infection is the apparent reason for

his elevated WBC count, which warrants another

course of antibiotic therapy. He should receive an I.V.


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insulin infusion and normal saline solution to correct

severe dehydration and hyperglycemia. Once his blood

glucose measures less than 250 mg/dl, dextrose can be

added to the I.V. infusion to prevent hypoglycemia

HHS is most common in elderly people with new-onset Type 2 diabetes, particularly those who live

in nursing homes, or in older people who have been diagnosed with Type 2 diabetes but who are

unaware that their blood glucose is high or who havent had enough fluid intake. Compounding the

problem is that the thirst mechanism can be impaired in older people, and theyre more apt to have

kidneyproblems, Dr. Hellman says. When a persons thirst mechanism is impaired, the kidneys

which normally work to remove excess glucose from the blood begin to conserve water. That

leads to a higher glucose concentration in the bloodstream.

In many people, HHS begins with an infection, such as a urinary tract infection or pneumonia. Unlike

DKA, which develops relatively quickly, HHS develops over several days, or even weeks.

Diagnosis is sometimes a problem, Dr. Hellman says. People with HHS look like theyre suffering

astrokeand may be vomiting. They have mental alterations that may look like a stroke or dementia

Symptoms of HHS include the following:

Dehydration

Excessive thirst

Lowblood pressure

High blood glucose level

Hallucinations

Sensory deficits, or impairment of one of the five senses, such as partial or total loss of hearing or

vision, loss of sensation in some part of the body, or a loss of sense of balance

Rapid eye movements

Paralysis on one side of the body

Seizures

A partial or total loss of the ability to comprehend spoken or written language and express ideas
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Is it DKA or HHS

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