Ketoacidosis versus hyperglycemic hyperosmolar state symptoms -
fluid replacement is key. The addition of dextrose counterbalances the insulin infusion, which needs to continue until acidosis is corrected, as indicated by normalization of bicarbonate and anion gap.
In addition, the dextrose infusion reduces the risk of cerebral edema, which can occur when blood glucose is corrected too rapidly. In most cases, the initial electrolyte imbalances should resolve on their own with I. Treatment with sodium bicarbonate is controversial.
It may lead to hypokalemia and impaired tissue oxygenation if it corrects acidosis too rapidly or to cerebral acidosis when cerebrospinal fluid pH is lowered. See Treating DKA outside of the ICU.
Managing diabetic ketoacidosis DKA in the ICU with I. No significant difference was shown to exist between the I. regular insulin group and the subcutaneous rapid-acting insulin group in time to DKA resolution or in rates of hypoglycemia. These studies typically excluded pregnant patients and those with hypotension or underlying cardiac, hepatic, or renal disease.
Those patients would be more safely treated in an ICU setting with I. regular insulin. Nurse staffing, education, and resources should be allocated to help ensure a smooth transition to treating DKA outside of the ICU when appropriate. This treatment option may help reduce healthcare costs and save ICU resources.
DKA is considered resolved with ketoacidosis correction, not improved glycemic control alone. Most importantly, to prevent DKA recurrence, the healthcare team should identify and treat any precipitating causes. After DKA resolves, the patient can be transitioned back to subcutaneous insulin, either in the form of multiple daily injections or a home insulin pump.
Most subcutaneous insulins have an onset of action from several minutes to several hours, but I. regular insulin infusion by 1 to 2 hours. Patients whose diabetes is normally well-controlled but have experienced DKA because of an accidentally missed insulin dose can resume home insulin doses.
However, for patients with an underlying illness or who must take steroids, home insulin doses may be inadequate to cover increasing demands. These patients may require higher insulin doses, which the provider will calculate by extrapolating from the previous 6 hours of stable I.
regular insulin infusion rates. Generally, the total daily insulin requirement for someone with Type 1 diabetes is 0. Therefore, caution should be used when re-starting what is documented as a home insulin dose.
Re-starting a dose that seems inordinately high relative to weight and I. regular insulin needs may result in hypoglycemia. A normally functioning pancreas secretes a basal dose of insulin, even in resting and fasting states, and releases insulin boluses within 8 to 10 minutes of ingesting food.
When patients are transitioning from I. regular insulin, in addition to basal insulin, they need rapid-acting insulin boluses to cover meals. These generally are administered in the form of an insulin-to-carbohydrate ratio for example, 1 unit of rapid-acting insulin for every 15 grams of carbohydrates consumed.
Rapid-acting insulin to cover meals is separate from correction-dose or sliding-scale insulin, which also should be in place and used to correct for hyperglycemia and to bring an elevated blood glucose level back within target range.
More importantly, sliding-scale insulin alone without basal insulin will result in a return to DKA. Basal insulin should never be withheld in patients with Type 1 diabetes because they have an absolute lack of endogenous insulin.
DKA prevalence is increasing worldwide, but a significant percentage of hospital admissions represents recurrent DKA with multiple hospital admissions in a calendar year. Most of these cases are caused by missed insulin doses rather than underlying illnesses. A number of factors are associated with recurrent DKA, including fragmented healthcare often involving admission to multiple hospitals , lower education levels, lower socioeconomic status, lack of health insurance, younger age, substance use, and other psychosocial issues.
In many cases, those with recurrent DKA have poor access to insulin and transportation. Studies by Desai and colleagues, Ehrmann and colleagues, and Gaffney and colleagues also point to recurrent DKA occurring more often in females than males, which may be related to eating disorders, missing insulin doses in an effort to lose weight, and other mental health concerns such as depression.
To reduce hospital admissions, DKA prevention strategies, especially for patients with multiple admissions, should be a component of care.
Improved patient and family education to help reduce hospital admissions and care coordination across the healthcare spectrum are key to prevention. Nurses can help patients obtain access to insulin particularly longer-acting basal insulins that allow for more dosing flexibility and diabetes technology such as insulin pumps and continuous glucose monitoring.
In addition, individual and family behavioral health coaching can help meet specialized needs such as addressing specific cultural or family concerns related to healthcare beliefs, foods, and periods of fasting.
As virtual appointments and telemedicine play an increasing role in healthcare, regular communication and follow-up between patients with recurrent DKA and healthcare providers can reduce admissions and improve healthcare engagement.
Virtual visits also may be helpful for those with transportation concerns or who live in areas with limited access to healthcare. In younger adults, the transition from pediatric to adult care can be challenging and frequently is associated with a period of declining glycemic control.
For older pediatric patients, smooth care transitions can be achieved by increasingly involving them in decision-making, including scheduling appointments and providing referrals to new providers and other individualized resources.
Several considerations, including insulin pumps, euglycemic DKA, and pregnancy, require special attention to prevent DKA recurrence. Insulin pumps.
DKA in someone who wears an insulin pump commonly occurs because of a disturbance kinked or dislodged tubing or air bubbles in insulin delivery. In addition, patients with scar tissue or lipohypertrophy may place their insulin pump site in an area of poor insulin absorption.
After DKA resolves, the patient should resume an insulin pump with a new infusion set, new insertion site, and new reservoir of insulin. Nurses should teach the patient to change injection sites and supplies according to manufacturer recommendations, which typically is every 2 to 3 days.
They also should remind patients to make changes only when they can closely monitor their glycemic control. These patients should have a supply of basal insulin and rapid acting insulin to use via injection if they encounter problems with the pump or supplies.
In the meantime, they should use multiple daily insulin injections until the pump can be resumed. Euglycemic DKA. DKA typically is defined by hyperglycemia, but euglycemic DKA may occur with normal or near-normal blood glucose levels. This is particularly true in cases of pregnant patients; starvation; insulin administration soon before hospital arrival; or those taking SGLT-2 inhibitors, which lower the renal threshold for glucose excretion through the urine.
Treatment for euglycemic DKA is the same as for DKA with hyperglycemia: I. If the patient is taking SGLT-2 inhibitors, the medication should be stopped.
Before any scheduled surgery or stressful physical activities, patients should stop taking SGLT-2 inhibitors. Pregnancy can result in increased insulin resistance, so women with pre-existing diabetes may require more insulin, particularly as their pregnancy progresses.
Missing insulin doses or failing to adequately adjust insulin in response to increasing insulin resistance can result in significant hyperglycemia and DKA.
In addition, ketogenesis increases during pregnancy, so DKA can occur at a lower glucose level than in nonpregnant individuals. Pregnant women with underlying diabetes should have access to ketone strips for self-monitoring.
Treating DKA in pregnancy includes I. fluids, but higher insulin doses and fluids with higher dextrose content may be needed, particularly later in pregnancy. DKA is associated with a high rate of stillbirth, so fetal monitoring is recommended.
HHS occurs in the presence of hyperglycemia, hyperosmolality, and dehydration but without ketosis. It typically occurs in older individuals with Type 2 diabetes and in those with underlying stressors such as stroke, cardiac disease, or pneumonia.
High carbohydrate intake, such as through tube feeding or I. nutrition, can lead to HHS, as can some medications, such as steroids and thiazide diuretics. doi: Hyperosmolar hyperglycemic state HHS is a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness.
HHS can occur if infections, nonadherence, and certain medications trigger marked glucose elevation, dehydration, and altered consciousness in patients with type 2 diabetes.
Patients have adequate insulin present to prevent ketoacidosis. The fluid deficit can exceed 10 L; treatment is 0. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge. Disclaimer Privacy Terms of use Contact Us Veterinary Manual. IN THIS TOPIC.
OTHER TOPICS IN THIS CHAPTER. Hyperosmolar Hyperglycemic State HHS By Erika F. View PATIENT EDUCATION. Symptoms and Signs Diagnosis Treatment Key Points. read more currently. It usually develops after a period of symptomatic hyperglycemia in which fluid intake is inadequate to prevent extreme dehydration due to the hyperglycemia-induced osmotic diuresis.
Acute infections and other medical conditions. Medications that impair glucose tolerance glucocorticoids or increase fluid loss diuretics. Blood glucose level. Serum electrolytes. Blood urea nitrogen BUN. Treatment is 0. Drugs Mentioned In This Article.
Drug Name Select Trade dextrose. All rights reserved. Was This Page Helpful? Yes No. Skip to main navigation Skip to content. Breadcrumb Home Guide to diabetes Complications Hyperosmolar hyperglycaemic state hhs. Save for later Page saved!
You can go back to this later in your Diabetes and Me Close. Hyperosmolar Hyperglycaemic State HHS. It can develop over a course of weeks through a combination of illness e.
Hyperosmolar HbAc tracking state is a metabolic stzte of diabetes mellitus characterized by dtate hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. Stzte most Family meal planning HbAc tracking in type 2 Ketoackdosis, often in the setting of physiologic stress. Hyperosmolar hyperglycemic state is diagnosed by severe hyperglycemia and plasma hyperosmolality and absence of significant ketosis. Treatment is IV saline solution and insulin. Complications include coma, seizures, and death. See also Diabetes Mellitus Diabetes Mellitus DM Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia Official websites use. gov A. symtoms website belongs to an official government versuss HbAc tracking the United States. gov website. Share sensitive information only on official, secure websites. Diabetic hyperglycemic hyperosmolar syndrome HHS is a complication of type 2 diabetes. It involves extremely high blood sugar glucose level without the presence of ketones.
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