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, and
blood 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
Urine or plasma ketones
Blood pH
Plasma osmolarity
GI findings (nausea, vomiting)

DKA
Always present
Low
Normal
Common

HHS
Absent or minimal
Normal
High
Absent

DKA
DKA results from uncontrolled hyperglycemia
associated with type 1 diabetes
In DKA,
extreme hyperglycemia leads
to lipolysis, which induces a
ketotic and acidotic state.

DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person
is dehydrated; and too many ketones are 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 have enough 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 dont have diabetes. Your body
sometimes 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 you exercise.
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 turn glycogen (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 your heart and, 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 Symptoms

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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

HHS
HHS, on the other hand,
stems from uncontrolled hyperglycemia associated with
type 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

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 HHS

Factors 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 findings
Onset of HHS occurs over 12 days, on average. If misdiagnosed,
the patient may suffer a serious medical
emergency by the time its correctly diagnosed

Acute management
Acute 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, normal
saline 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.

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
kidney problems, 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
a stroke and may be vomiting. They have mental alterations that may look like a stroke or dementia

Symptoms of HHS include the following:

Dehydration
Excessive thirst
Low blood 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