Piece of Cake: DKA/HHS Update Part II with George Willis
Feb 18, 2025
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Join George Willis, an endocrinology expert, as he unpacks the 2024 ADA consensus report on diabetic emergencies. They delve into revised diagnostic criteria for DKA and HHS, shedding light on new glucose testing methods and the vital role of beta hydroxybutyrate. Discover advancements in treatment protocols, including fluid administration and potassium management, while challenging old beliefs. Willis emphasizes the critical differences between DKA and HHS, the importance of patient education, and innovative approaches to diabetic emergencies.
The updated diagnostic criteria for DKA lower the glucose threshold to 200 mg/dL, enhancing early identification of cases.
New treatment guidelines recommend balanced fluid solutions for DKA management, shifting away from the traditional use of normal saline.
For HHS, a gentler insulin infusion strategy is emphasized to prevent rapid sodium shifts while ensuring patient rehydration.
Deep dives
Updated Diagnostic Criteria for DKA
The new guidelines for diagnosing Diabetic Ketoacidosis (DKA) now set the glucose threshold for diagnosis at 200 mg/dL, a notable decrease from the previous standard of 250 mg/dL. This adjustment aims to better identify cases, particularly euglycemic DKA, where patients can present with normal glucose levels but still have underlying DKA. The updated criteria also include the consideration of beta-hydroxybutyrate levels as a critical diagnostic tool, which can now be checked at point-of-care rather than dependent on delayed lab results. These changes are intended to refine diagnostic accuracy and ensure timely treatment for patients at risk of DKA.
Management of Mild to Moderate DKA
Recent guidelines highlight the importance of using balanced solutions, like lactated Ringer's or PlasmaLyte, as the primary fluid resuscitation method for patients with DKA instead of the traditionally recommended normal saline. Furthermore, the introduction of the SQUID protocol allows for subcutaneous insulin administration in managing mild to moderate DKA, potentially reducing ICU admissions and streamlining treatment in emergency departments. Patients who meet specific criteria can benefit from this protocol, which aims to expedite recovery without the need for continuous intravenous insulin infusion. By shifting toward this new management approach, the treatment burden on healthcare resources can be alleviated while still ensuring patient safety.
Diagnostic Workup for HHS
For Hyperglycemic Hyperosmolar State (HHS), the recent guidelines urge clinicians to be cautious, as the condition presents differently than DKA and often requires a more gradual correction strategy. Patients with HHS typically have higher glucose levels but must be treated delicately to avoid rapid shifts in sodium levels, which could lead to complications. Initiating treatment with a lower insulin infusion rate of 0.05 units per kilogram per hour is recommended, emphasizing a focus on adequately rehydrating patients to restore their fluid balance without causing electrolyte disturbances. Understanding the chronic nature of HHS, as compared to the acute presentation of DKA, is essential for effective management.
Key Considerations in DKA and HHS Management
Monitoring potassium levels remains a critical component in the treatment of both DKA and HHS, as insulin therapy can lead to shifts in potassium that may result in hypokalemia. Clinicians are advised to supplement potassium as needed based on the patient's levels and overall clinical picture. The management of patients should also incorporate a focus on addressing any underlying triggers, such as infections or medication non-compliance, to reduce the risk of recurrent hyperglycemic crises. Furthermore, vigilance for potential complications like hypoglycemia and cerebral edema is imperative to ensure patient safety throughout their treatment in the emergency department.
Preventive Strategies for Future Crises
To minimize the recurrence of DKA and HHS, ensuring that patients have adequate access to outpatient care and resources is paramount. Clinicians should actively engage social work teams in emergency departments to connect patients with necessary healthcare services, medications, and follow-up appointments. Educating patients about managing their diabetes, recognizing warning signs, and the importance of adherence to their treatment plan can significantly improve long-term outcomes. Fostering support systems for patients, including mental health resources and education, plays an integral role in preventing future episodes of hyperglycemic crises.
The American Diabetes Association released a consensus report in 2024 on the management of the hyperglycemic crises: DKA and HHS. Our goal is to give you some insight into the latest recommendations on the management of these critical presentations using this report and Dr. George Willis as our guide!
In Part II, we continue our deep dive into with a focus on diagnostic criteria updates and new treatment guidelines. We break down the latest consensus statement and discuss how these changes impact clinical practice.
