Chapter 25: Diabetic Ketoacidosis and Hyperosmolar Coma

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute complications of diabetes mellitus (DM). DKA is seen primarily in individuals with type 1 DM and HHS in individuals with type 2 DM. Both disorders are associated with absolute or relative insulin deficiency, volume depletion, and altered mental status. The metabolic similarities and differences in DKA and HHS are summarized in Table 25-1.

TABLE 25-1: Laboratory Values in DKA and HHS (Representative Ranges at Presentation)
	DKA	HHS
Glucose,^a mmol/L (mg/dL)	13.9–33.3 (250–600)	33.3–66.6 (600–1200)^c
Sodium, meq/L	125–135	135–145
Potassium,^a meq/L	Normal to ↑^b	Normal
Magnesium^a	Normal^{^b}	Normal
Chloride^a	Normal	Normal
Phosphate^a	Normal to ↓^b	Normal
Creatinine, µmol/L (mg/dL)	Slightly ↑	Moderately ↑
Osmolality (mosmol/mL)	300–320	330–380
Plasma ketones^a	++++	±
Serum bicarbonate,^a meq/L	<15 meq/L	Normal to slightly ↓
Arterial pH	6.8–7.3	>7.3
Arterial PCO₂,^a mmHg	20–30	Normal
Anion gap^a [Na – (Cl + HCO₃)], meq/L	↑	Normal to slightly ↑

^aLarge changes occur during treatment of DKA.

^bAlthough plasma levels may be normal or high at presentation, total-body stores are usually depleted.

^cLarge changes occur during treatment.

Abbreviations: DKA, diabetic ketoacidosis; HHS, hyperglycemic hyperosmolar state.

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