Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State Signs and Symptoms

Definition

  • Diabetic ketoacidosis (DKA) is the presence of ketoacidosis and hypergylcemia
  • Hyperosmolar hyperglycemic state (HHS) is characterized by more severe hyperglycemia but without ketoacidosis

Epidemiology

DKA
  • More common in patients with type 1 diabetes mellitus (DM)
  • May occur in patients with type 2 DM under conditions of extreme stress (eg serious infection, trauma, cardiovascular or other emergencies)
  • More common in young patients (<65 years)
HHS
  • More common in patients >65 years

Pathogenesis

  • Due to insulin deficiency and/or resistance and excess of glucagon resulting from removal of the normal suppressive effect of insulin and other counterregulatory hormones (eg catecholamines, cortisol, growth hormone)
    • Leads to lipolysis causing the release of free fatty acids into the circulation which in turn leads to unrestrained hepatic fatty acid oxidation in the liver to ketone bodies resulting to ketonemia and metabolic acidosis
    • Patients with HHS have greater degree of dehydration due to osmotic diuresis, with inadequate levels of insulin to facilitate glucose utilization by insulin-sensitive tissue but adequate to prevent lipolysis and subsequent ketogenesis
  • Hyperglycemia is a result of increased gluconeogenesis, accelerated glycogenolysis and impaired glucose utilization by peripheral tissues

Risk Factors

Precipitating Factors
  • Infections are the most common
  • Inadequate, poor compliance to or discontinuation of insulin therapy
  • Burns
  • Cerebrovascular accident (CVA)
  • Cocaine use
  • Drugs (eg corticosteroids, Pentamidine, sodium-glucose co-transporter 2 [SGLT2] inhibitors, sympathomimetic agents, thiazides, second-generation atypical antipsychotic agents)
  • Myocardial infarction (MI)
  • New onset type 1 DM
  • Omission or discontinuation of insulin in established type 1 DM in setting of gastroenteritis
  • Pancreatitis
  • Psychological problems associated with eating disorders and omission of insulin due to fear of weight gain, fear of hypoglycemia, rebellion from authority and stress of chronic disease
  • Sepsis
  • Surgery
  • Trauma