DKA and HHS

Question 1

what is diabetic ketoacidosis

Answer 1

lack of insulin means cells aren’t getting enough glucose so switch to lipolysis for energy.

This causes excess ketones to be in the blood which make the blood acidic.

Question 2

what is the pathophysiology of ketoacidosis

Answer 2

insulin deficiency leads to stress hormone activation which casues

• inctreased lipolysis
• decreased glucose utilisation
• increased proteolysis
• incresed gluconeogenesis

Question 3

what is the biochemical diagnosis of ketoacidosis

Answer 3

ketonaemia >3mmol/l or significant ketonuria (>2 on urine stick)

blood glucose >11

bicarbonate <15

Question 4

what causes ketoacidosis

Answer 4

lack of insulin leads to body breaking down fat instead of glucose gives ketones as a biproduct

Question 5

causes of death in DKA

Answer 5

hypoalkalaemia
aspiration pneumonia
co-morbitities

in children - cerebral oedema

Question 6

what precipitates DKA (risk factors)

Answer 6

newly diagnosed
infection
illicit drug and alcohol use
non-adherence to insulin/poor self management

Question 7

typical symptoms and signs

Answer 7

thirst
polyuria

ketone body related: 
flushed 
vomiting 
abdominal pain and tenderness 
breathless 
can smell ketones on breath (85% of people can) 

associated conditions:
underlying sepsis
gastroenteritis

Question 8

what is the classical DKA biochemistry at diagnosis

Answer 8

glucose (usually 40 but could be from 11-100)
potassium often raised to above 5.5mmol/l
creatine often raised
sodium often low
raised lactate is common
amylase raised
white cell count 25

Question 9

what measure of blood ketones is common on DKA presentation

Answer 9

> 5 (>3 is bad)

Question 10

what is bicarbonate in DKA presentation

Answer 10

<10 in severe cases (<15 is bad)

Question 11

complications of DKA

Answer 11

cardiac arrest secondary to hypokalaemia
adult respiratory distress syndrome
cerebral oedema
gastric dilation - risk of aspiration

Question 12

Management principles for DKA

Answer 12

manage in HDU
replace losses
fluids - once glucose falls to around 15 switch to dextrose
insulin
potassium
phosphate and bicarbonate replaces (rare)

address risks

• is a nasogastric tube needed
• monitor K+
• prescribe prophylactic LMWH
• source sepsis, CXR, blood culture

Question 13

how do you measure ketones

Answer 13

blood ketone testing

• should be <0.6
• measures beta-hydroxybutyrate

urine ketone testing

• indicated levels 2-4 hours previously
• measures acetoacetate

Question 14

what is hyperglycaemic hyperosmolar syndrome pathophysiology

Answer 14

insulin deficiency 
stress hormone activation 
high blood sugars (higher than DKA) 
become hypersmolar 
less acidosis

Question 15

biochemistry of hyperglycaemic hyperosmolar syndrome at diagnosis

Answer 15

hypovolaemia - usually marked 
marker hyperglycaemia >30 
no/mile ketonaemia <3 
bicarbonate >15 
osmolarity >320

Question 16

typical features of HHS

Answer 16

diabetes may be known at presentation (often not)
older patients
you afro-caribbean
high refined CHO intake pre-presentation

Question 17

risks for HHS

Answer 17

cardiovascular disease
sepsis
medication: steroids/thiazide diuretics

Question 18

key differences between DKA and HHS

Answer 18

DKA - younger HHS- older 
DKA-type 1 HHS-Type 2
DKA - insulin omission HHS- newly diagnosis infection 
DKA-<2% mortality HHS- 10-15% mortality 
DKA- treat with insulin 
HHS- treat with diet/OHA

Question 19

what is the biochemistry at diagnosis for alcoholic/starvation ketoacidosis

Answer 19

HISTORY 
dehydration is common 
ketonaemia >3 or significant ketonuria 
bicarbonate usually <15
Glucose usually normal - may be low