Piece of Cake: DKA/HHS Update Part I with Dr. George Willis
Feb 3, 2025
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Join Dr. George Willis, an expert in endocrinology, as he dives into the latest American Diabetes Association guidelines on DKA and HHS management. The discussion unveils the rising prevalence of these hyperglycemic crises and emphasizes the critical role of mental health in effective diabetes care. Dr. Willis highlights the complex pathophysiology of DKA, the importance of sodium levels in HHS, and offers vital insights for recognizing these conditions in pediatric patients, especially during respiratory illnesses.
The 2024 ADA consensus guidelines highlight the increasing incidence of DKA and HHS, necessitating updated management protocols for improved patient outcomes.
Understanding the distinct pathophysiological mechanisms of DKA and HHS is crucial for emergency providers to effectively recognize and treat these hyperglycemic crises.
Deep dives
Introduction of New Guidelines
The release of the 2024 ADA consensus guidelines is a significant advancement in managing diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), updating recommendations that had been in place since 2009. This new set of guidelines incorporates research and recommendations from various international diabetic organizations, reflecting a more comprehensive approach to patient management. Key updates include the recognition of euglycemic DKA and new treatment management protocols, which are essential for both emergency and primary care providers. These updated guidelines serve to enhance clinical practice and improve patient outcomes, particularly in patients experiencing complex hyperglycemic crises.
Rising Incidence of Hyperglycemic Crises
The episode discusses the increasing incidence of DKA and HHS, highlighting the disturbing trend of rising diagnoses despite previous declines in cases. Economic factors, such as the rising cost of insulin and lack of insurance for many patients, contribute significantly to this situation as many patients resort to rationing their insulin doses. This leads to inadequate management of their diabetes, resulting in hyperglycemic emergencies. Furthermore, mental health issues associated with diabetes management often compound these challenges, underscoring the need for a multifaceted understanding of patient care.
Pathophysiological Insights into DKA and HHS
The podcast elucidates the distinct pathophysiological mechanisms underlying DKA and HHS, emphasizing that DKA occurs in the absence of effective insulin utilization despite high glucose levels, leading to the production of ketone bodies. Stress factors such as infection or injury can precipitate DKA even in patients with type 2 diabetes, as elevated cortisol levels inhibit insulin production. Knowledge of the “five I’s” is essential for clinicians to recognize potential triggers of DKA, including infection, ischemia, insulin deficiency, infant-related complications, and now medications like SGLT2 inhibitors. In contrast, HHS is characterized by severe hyperglycemia and dehydration but typically has functional insulin sparing patients from ketogenesis, highlighting the critical differences in their management.
Clinical Considerations for Diagnosis
Clinical recognition of DKA and HHS in emergency settings can be nuanced, given the symptoms often overlap with common illnesses such as respiratory infections. The presence of tachypnea, altered mental status, and persistent vomiting are key indicators, particularly in cases where patients do not respond to initial treatments. In pediatric patients, unexplained tachycardia coupled with gastrointestinal symptoms may warrant consideration of DKA, especially if the standard treatments are ineffective. Utilizing a thorough clinical evaluation, including checking blood glucose levels, is vital in diagnosing these conditions accurately and promptly.
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 I, we discuss epidemiology, pathophysiology, and clinical presentation of DKA/HHS. In Part II, we will discuss diagnosis and clinical management.