S What is the pt’s age?

Certain age groups are more likely to present with DKA versus HONK.
_ DKA is common in young type 1 DM, also seen with type 2.
_ HONK is common in older pts, seen in type 2.
Does the pt report any of the 3 P’s (polyuria, polydipsia, polyphagia)?
Common clinical manifestations of uncontrolled hyperglycemia:
_ Polyuria: frequent urination caused by glycosuria
_ Polydipsia: frequent drinking driven by dehydration and hyperosmolarity
_ Polyphagia: increased food intake often with weight loss
Does the pt report recent illness?
Decompensated glycemic control results from underlying infections
- Urinary tract infection - Pneumonia - Pancreatitis
Other factors that may precipitate hyperglycemia
- Myocardial infarction (MI) - Cerebrovascular accident
- Alcohol binge - Pregnancy - Trauma
Does the pt have a history of lack of adherence to medications or
nutrition?
Nonadherence is one of the most common causes of poorly controlled sugars.
Review medications
Diuretics and steroids can increase blood sugars.

O Does the pt have VS suggestive of hemodynamic instability?

Consider the following in a pt who presents with severe hyperglycemia:
_ Sepsis : fever, hypotension, tachycardia
_ Respiratory distress : tachypnea (Kussmaul respirations)
_ Severe volume contraction: orthostatics
Perform a PE
Gen: Assess level of consciousness (obtunded); evaluate for acetone breath.
Look for signs of infection.
Perform diagnostic tests to differentiate DKA from HONK
Check finger stick.
Check arterial blood gas (ABG).
_ Low pH in DKA, normal in HONK
Check serum electrolytes, including calcium, magnesium, and phosphorus.
_ Calculate anion gap.
◆ Highin DKA, normal in HONK
Check serum ketones.
_ High in DKA, none/decreased in HONK
Calculate serum osmolality: increased in HONK.
_ 2 × (observed Na ++ K+) + glucose/18 + BUN/2.8
What is the result of the CBC with differential?
Leukocytosis with left shift indicates infection.
_ Consider U/A, blood, urine and sputum cultures, and CXR.
What are the results of the pt’s renal and liver function tests (LFTs)?
Pts who are severely volume contracted typically have a rise in BUN and creatinine.
Abnormal LFTs suggest infection or alcohol-induced.
Endocrinology Diabetic Ketoacidosis and Hyperosmolar Nonketotic Coma 129
Consider the ECG
MI is a common precipitant of a severe hyperglycemic state.
Arrhythmias are common with electrolyte abnormalities.

A Severe Hyperglycemia
Diabetic Ketoacidosis
_ DM: hyperglycemia (glucose > 300 mg/dL)
_ Ketonuria, ketonemia, or both
_ Acidosis pH < 7.35, bicarbonate < 15
Hyperosmolar Nonketotic Coma
_ Hyperglycemia (glucose > 400 mg/dL)
_ Impaired mental status
_ High plasma osmolality (> 340 mOsm)
_ Lack of significant ketosis

P Admit to a monitored bed

DKA and HONK are life-threatening conditions.
Treat precipitating factors
As mentioned above, many things can cause or precipitate DKA/HONK; look for these
causes and treat them or the pt will not get better.
Provide aggressive fluid resuscitation immediately, even before insulin
These pts (HONK > DKA) are very volume depleted.
Estimated free water deficit = 0.5 × body wt (kg) × (corrected Na+-140/140)
Initial volume replacement with normal saline (NS). Replace 1 L in first hour, 2nd L in
next 1 to 2 hours, and then continue 1/2NS 500 mL/hr.
Add D5 to IV fluid when glucose levels approach 250 mg/dL
To avoid rebound hypoglycemia
IV insulin therapy: load 0.1 to 0.2 U/kg IV and then continuous infusion
0.1U/kg/hr
This will decrease serum glucose concentration.
Continue until anion gap [AG = Na – (Cl + HCO3)] is closed (AG < 15).
SQ dose of regular insulin 30 minutes before stopping infusion
Make a flow sheet of important electrolytes and glucose to carefully
follow and replace electrolytes
In hyperosmolar states, the electrolytes K, Ca, Mg, and Phos will be artificially high in
the serum because of the lack of insulin. So it is important to monitor them carefully
in order to avoid dangerous sequelae of low serum electrolytes (such as arrhythmia)
as the insulin is replaced.
Finger sticks every hour initially
Carefully avoid hypoglycemia (remember to add D5 when the blood sugar approaches
250) and make sure your interventions are working.
Electrolytes, anion gap q2 hrs initially. P, Mg q6 hrs initially
As mentioned above, treatment is not over until AG < 15, and these pts will nearly
always require electrolyte replacement.
Repeat ABG after 4 hrs
Another way of verifying that your interventions are working.