The Threats: Hyperclycemic Hyperosmolar Syndrome and Diabetic KetoAcidosis

So why all the talk of HHS &  DKA? Let’s briefly go over what HHS and DKA are and what makes them different, and why they are such a sick day risk.

Hyperglycemic Hyperosmolar Syndrome (HHS) is caused when blood sugars are very high. When blood glucose is elevated the body tries to clear it through urination, but if our fluid intake is not sufficient to replace the water and electrolytes lost in urination, there will also be insufficient hydration for proper organ functioning (including the brain). Typically this syndrome takes days or even weeks to build, but on a sick day, where hydration may already be reduced and blood sugars are pushed even higher, the risks increase dramatically. This is especially evident in the very young, or geriatric patients.

Symptoms typically include blood glucose levels over 400, thirst, rapid heart rate, single sided weakness, nausea/stomach pain, frequent urination, and confusion. These symptoms are often confused with UTI's.

Diabetic Keto Acidosis (DKA)

This is a life threatening state where an elevation of ketones in the blood stream causes an imbalance of pH in the blood.

Looks a lot like illness huh? This is why we should never judge DKA by symptoms on a sick day, we simply can’t tell them apart!

This imbalance can lead to, among other things, cardiac arrythmia or heart attack, cerebral edema, coma, multi-system organ failure, or even death.

So what causes excessive ketones?

How can we monitor for and treat ketones at home to avoid hospitalization?

Ketone testing supplies should be available to all patients with diabetes. Urine test strips are the lowest cost option, these dip sticks change color, which is then indexed against the key on the container to determine size of ketones present. A quicker and more precise option are blood-based ketone meters. These work just like glucometers (In fact some double as glucometers) using a test strip and a small blood sample. These are faster and more precise as the reading is not open to interpretation. They are also required for any patient with diabetes who also has color blindness or a visual impairment that keeps them from using the dipsticks. They are also recommended for patients with severe renal impairments as they may not be clearing ketones in urine below life threatening levels.

Once we have a ketone measurement we can correlate that to an action via a ketone action guide, another resource all patients should have. This directs patients that for trace ketones no action is needed.

For small-moderate ketones they should consider changing infusion sets, eating, or giving a small dose of insulin. They should also reach out to their healthcare team. However this is not a life-threatening level and with effective hydration ketones should stay at this level or reduce to normal.

For moderate-large ketones the patient is at high risk for DKA and should seek urgent medical assistance, particularly if they have symptoms of DKA.

These targets should also be adjusted for the patient’s individual risk factors.