DKA

Feature	Diabetic Ketoacidosis (DKA)	Hyperosmolar Hyperglycemic State (HHS)
DM	主要是Type 1 Diabetes, but can occur in Type 2	More common in Type 2 Diabetes
高血糖	>250 mg/dL	>600 mg/dL
Ketone	High (至少>0.6 mmol/L)	Rare or minimal ketosis
代謝性酸中毒	pH <7.3	Absent or minimal, pH >7.3
脫水	less severe	Severe dehydration
Osmolality	<320 mOsm/kg	>320 mOsm/kg
症狀	Nausea, vomiting, abdominal pain, Kussmaul breathing 症狀明顯所以不會拖到太嚴重才來就醫	Dehydration, cons. change, less abdominal pain
死亡率	lower, 0.2~1.04%	Higher, 5~15%
發病	Develops over hours to days	Develops over days to weeks
Precipitating Factors (Triggers)	- Infections (e.g., UTI, pneumonia) - Missed insulin doses - Pregnancy - Trauma - Certain medications (e.g., corticosteroids, SGLT2i) - Alcohol/drug misuse	- Similar to DKA, with additional factors like certain medications and lack of access to water
Treatment	- Fluid Resuscitation: IV 0.9% saline initially, followed by 0.45% saline. - Insulin Therapy: Low-dose IV insulin (0.1 unit/kg/hr) after potassium levels are adequate. - Potassium Replacement: To prevent hypokalemia. - Monitoring: Frequent checks for electrolytes, glucose, and ketones.	- Aggressive Fluid Resuscitation: more than DKA  due to severe dehydration. - Insulin Therapy: Similar to DKA, but may start at lower doses due to less ketosis- 0.05U/kg/hr - Electrolyte Replacement: Similar to DKA. - Monitoring: Close monitoring for complications, especially neurological.

SGLT2i造成的euDKA(血糖200多mg/dL)是近年來的顯學，大手術的前2-3天應DC，上圖中的這些情況都是risk factor，應避免使用SGLT2i

標準治療: 大量給水、持續給Insulin、維持血鉀4-5 mmol/L
bicarb、phosphate都不用常規給，因為沒好處，除非pH<7.0、或是P<1 mmol/L才短暫給予

另外注意，高血糖時，血鈉需要校正，會變高，不要以為看到低血鈉就窮緊張，血糖校正回來數值就會正常了~

但其實臨床上有兩條公式係數
(血糖<400 mg/dL時使用Katz,1973) 校正後Na (mEq/L) = 檢驗值Na mEq/L+ 0.016 * (血糖mg/ dL – 100) 

(血糖>400 mg/dL時使用Hillier,1999) 校正後Na (mEq/L) = 檢驗值Na mEq/L + 0.024 x (血糖mg/dL - 100) 

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Uptodate DKA治療流程

DKA diagnostic criteria: Hyperglycemia (eg, for new-onset diabetes, glucose ≥200 mg/dL [11.1 mmol/L]), venous pH <7.3, serum bicarbonate <18 mEq/L, and at least moderate ketonuria (≥2+) or ketonemia (BOHB ≥3 mmol/L). Normal laboratory values vary; check local laboratory reference ranges for all electrolytes.

For monovalent ions (eg, K+, HCO3–), 1 mEq/L = 1 mmol/L.

BOHB: beta-hydroxybutyrate; BUN: blood urea nitrogen; DKA: diabetic ketoacidosis; HCO3: bicarbonate; IV: intravenous; K+: potassium; KCl: potassium chloride; Na+: sodium; NaCl: sodium chloride; NaHCO3: sodium bicarbonate; STAT: intervention should be performed emergently; SUBQ: subcutaneous.

* After history and physical examination, obtain capillary glucose and serum or urine ketones. Begin 1 L of 0.9% NaCl (or buffered crystalloid [eg, Lactated Ringer]) over 1 hour, and draw arterial blood gas (or mixed venous blood gas), complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT. Obtain electrocardiogram and, if needed, chest radiograph and specimens for bacterial cultures.

¶ Serum Na+ should be "corrected" for hyperglycemia (for each 100 mg/dL increase in glucose above 100 mg/dL, add 2 mEq to sodium value for corrected serum sodium value).

Δ As an alternative to fixed-rate insulin infusion, a variable-rate infusion may be administered based on a nurse-driven protocol.

HHS diagnostic criteria: Hyperglycemia (glucose ≥600 mg/dL [33.3 mmol/L]), serum osmolality >300 mOsm/kg, arterial pH >7.3, serum bicarbonate >18 mEq/L, and minimal ketonuria (<2+) or ketonemia (BOHB <3 mmol/L). Normal laboratory values vary; check local laboratory reference ranges for all electrolytes.

If acidosis and/or at least moderate ketonemia/ketonuria are present, presentation is consistent with DKA or mixed DKA/HHS. Refer to UpToDate content on the treatment of DKA in adults.

For monovalent ions (eg, K+), 1 mEq/L = 1 mmol/L.

BOHB: beta-hydroxybutyrate; BUN: blood urea nitrogen; DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state; IV: intravenous; K+: potassium; KCl: potassium chloride; Na+: sodium; NaCl: sodium chloride; STAT: intervention should be performed emergently; SUBQ: subcutaneous.

* After history and physical examination, obtain capillary glucose and serum or urine ketones. Begin 1 L of 0.9% NaCl (or buffered crystalloid) over 1 hour, and draw arterial blood gas (or mixed venous blood gas), complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT. Obtain electrocardiogram and, if needed, chest radiograph and specimens for bacterial cultures.

¶ Serum Na+ should be "corrected" for hyperglycemia (for each 100 mg/dL increase in glucose above 100 mg/dL, add 2 mEq to sodium value for corrected serum sodium value).