DKA, HHS (Hyperglycemic Hyperosmolar Syndrome)

Question 1

What are the main differences between a patient presenting with DKA vs HHS?

Answer 1

Difference:
- HHS does not cause lipolysis, so no ketones present unlike DKA
- K+ usually normal in HHS, low K+ with DKA
- Azotemia markedly elevated in HHS
- BG usually ~350 in DKA, ~600 in HHS
- More neuro signs with HHS

Question 2

Concurrent disease is documented in ____% of dogs and _____% of cats with DKA

Answer 2

70, 90

Question 3

Explain the pathophysiology behind how DKA can lead to severe hyperglycemia and ketonuria?

Answer 3

• Lack on insulin or insulin resistance
• ↑ BG in blood can’t be stored or utilized by tissues
• This stimulates ↑ gluconeogenesis + glycogenolysis
• Body undergoes lipolysis in demand for energy → ↑ FFA → ↑ ketone production

Question 4

What ketone is primarily secreted in the urine?

A. Acetoacetate
B. B-hydroxybutyrate
C. Acetone

Answer 4

B. B-hydroxybutyrate

(problem is the urine dipstick only measures acetoacetate)

Question 5

What ketone can be identified when using a urine dipstick?

A. Acetoacetate
B. B-hydroxybutyrate
C. Acetone
D. All of the above

Answer 5

A. Acetoacetate

(B-hydroxybutyrate is most commonly secreted.. over time (chronic) it will convert to acetoacetate which can be picked up on urine dipstick)

Question 6

What can be added to a urine sample to convert B-hydroxybutyrate to acetoacetate ketones that can be read on a ketone meter?

Answer 6

H2O2 (hydrogen peroxide)

Question 7

Since the urine dipstick is not sensitive to all ketones excreted in urine, how else can ketones be measured?

Answer 7

Plasma ketones, 100% sensitivity

Question 8

Why do DKA patients present dehydrated?

Answer 8

Glucosuria causing osmotic diuresis

H20 being excreted due to glucose pull

Question 9

List the major electrolyte imbalances seen with DKA patients

Answer 9

1. Hypokalemia (from lack of insulin + osmotic diuresis from hyperglycemia)
2. Hypophosphotemia
3. Hypomagnesemia

(50% of dogs have low Na, Cl, and iCa)

Question 10

Why do DKA patients present with hypokalemia?

Answer 10

• Due to impaired insulin
• Further loss from osmotic diuresis due to glucosuria

Question 11

What is the leading cause of death in DKA patients?

Answer 11

Hypovolemia and Hypotension (Low BP)

Question 12

What is the goal of treating DKA patients?

Answer 12

• Correct volume depletion and electrolyte deficiencies

Question 13

What is an adverse effect of phosphate levels dropping below 0.5 mmol/L?

Answer 13

Hemolysis

Question 14

A patient in DKA with hypokalemia and hypophosphatemia needs fluids. What do you give?

Answer 14

KPO4 added to 0.9% NaCl (not LRS)

Question 15

How is insulin implemented in the treatment of DKA patients?

Answer 15

• Don’t give insulin until hypovolemia and hypokalemia is fixed! (after IV fluids)
• Once those are fixed give IV insulin (NPH) SLOWLYYYY

(If insulin is given before correction, can worsen hypokalemia)

Question 16

How do idiogenic osmoles in the brain effect the treatment of DKA and HHS?

Answer 16

When dropping BG too quick with insulin, brain can’t eliminate as fast…. causes inc. osmolarity in brain vs body….. fluid will travel into brain to dilute osmoles…. cerebral edema

Question 17

_____% of cats in DKA have recurrent episodes

Answer 17

40% (7% in dogs)

Question 18

What is the treatment protocol for a patient with HHS?

Answer 18

• Isotonic fluids while checking BG and electrolytes every hour
• Give fluids until Na+ is normal (>135)
• Add dextrose once glucose is 250-300
• Give insulin IV (NPH) (only if normal K+), aim to reach BG of 250-300, then switch to SC insulin

Question 19

List the treatment plan in order for managing DKA patients

Answer 19

1. IV fluids to correct hypovolemia
2. K+ and Phosphate supplementation (KPO4, KCL added to 0.9% NaCl)
3. Only start IV insulin slowly when K+ > 3.5
4. Stop insulin once reaching appropriate BG
5. Once hydrated and eating switch to SC insulin
6. Correct acidosis w HCO3 if pH <7 (rarely needed)

Question 20

List the major electrolyte imbalances seen with HHS patients

Answer 20

• Sodium may be low or high depending on volume deficit
• K+ usually normal

Question 21

What clinical signs do DKA patients present with?

Answer 21

• PU/PD
• Hypotension (low BP)
• Hypothermic
• Vomiting, anorexia, weight loss
• Mentation change
• ABD pain
• Hepatomegaly/icterus
• Anemic (50% of dogs)