Fluid and electrolyte management in Diabetic Ketoacidosis and Hyperosmolar Hyperglycaemic state in the emergency department
Diabetes Mellitus is a growing issue for health care providers internationally. The World Health organization estimated in 2013 there were 347 Million diabetics worldwide, predicting that Diabetes will be the 7th leading cause of death by 2030 (WHO, 2013). In both type 1 and type 2 diabetes Mellitus, factors such as poor compliance with diet and medication, infection, acute medical or surgical illness or trauma can lead to poor glycaemic control, precipitating a hyperglycaemic emergency such as Diabetic Ketoacidosis (DKA) (Scobie & Samaras, 2009). In Type 2 Diabetes, another equally dangerous complication can occur called Hyperosmolar, hyperglycaemic state (HHS) (Dunning, 2009). Both DKA and HHS are characterized by dehydration resulting from osmotic diuresis (Kisiel & Marsons 2009), often compounded by the patient already being in a dehydrated state due to the underlying cause (Del Garcia-Pascual & Kidby, 2012). It is therefore imperative that when a patient presents to an emergency department, rehydration and electrolyte replacement forms an integral component of treatment. Monash Health has developed protocols to treat DKA and HHS, a large part of which focus on rehydration and electrolyte management. This review will discuss the mechanisms of Dehydration in DKA and HHS, the importance of an effective rehydration and electrolyte management in both conditions; examine the differences between DKA and HHS in terms of onset, volume deficit and electrolyte changes, and compare best practice recommendations with the policies currently adopted by Monash Health.
What are DKA and HHS?
DKA and HHS are both hyperglycaemic emergencies, a category of presentations where patient’s present with uncontrolled blood sugar levels (Lowth, M., 2012). DKA is the result of Insulin failing to transport glucose into the cells. In a healthy individual, carbohydrates are broken down into glucose, which is shifted into the cells by insulin for use as energy. In a diabetic with impaired insulin production, the lack of insulin available to allow this process to occur means that the glucose begins to build up in the blood, and the cells are starved of the energy they need to function (Buckley, T., & Murphy, M., 2011). This creates two problems. Firstly, the buildup of glucose in the blood leads to a hyperosmolar state. The urinary system will attempt to excrete the glucose, but with this are excreted large amounts of fluids and electrolytes, a scenario called osmotic diuresis (Buckley, T. & Murphy, M., 2011). This means the blood sugar level (BSL) may appear only mildly elevated. Osmotic diuresis however is only half the story. With the cells now starved of an energy supply, the body’s own fail safe mechanisms begin to kick in. It assumes that the body is starving, and begins using the energy supplies stored as fat. (Bilous, R. &...