Hyperglycemic Crises: DKA and HHS - Part 1 of 2

A lecture on the recognition, pathogenesis, and management of diabetic ketoacidosis and the hyperosmolar hyperglycemic state.
Use of the VA and Stanford name/logos is only to indicate my academic affiliation, and neither implies endorsement nor ownership of the included material.

[@Theteaspot5]

Thank you so much for posting the video. As a nursing student, I'm getting a head start on reading for the semester. After my textbook reading and watching your video, I have a much better understanding of DKA and HHS, and feel confident in the material for when classes start! Again, THANK YOU!!:):)

[@docsanti8971]

By far the best explanation I’ve ever seen. Thanks a lot doctor!

[@Lemonz1989]

I've experienced severe DKA before being diagnosed with type 1 diabetes. You have an extreme unquenchable thirst, that is absolutely never satisfied. You only become full from drinking water, which was the only limiting factor for my water intake at the time. You get constant and very painful leg cramps, and I personally urinated 400 to 500 ml each time. Sometimes I would just sit on the toilet waiting until I had to pee again. My hands were so dry I soaked them in water multiple times a day, just to relieve the tightness of the skin. My mouth was really dry and had a constant bad taste, so I was chewing gum during all my waking hours. I could sleep 15 to 20 hours a day. During the last day I vomited so much that I almost had no time to sleep in between the episodes and I had to pee between every episode of vomiting. And there was a never ending stream of fluid coming out of me; not like a normal stomach-flu where you run out of stuff to vomit out. My breathing became really deep, without me being able to control it, and it felt like I was suffocating. Then I got really bad chest pains and I started to becomes confused, and a few minutes later the ambulance was there and I was whisked away to the hospital where I spent 10 days recovering and learning to live with diabetes. That was 12 years ago, and I still remember it vividly.

[@StrongMed]

Thanks for sharing your story! DKA can be a truly horrible and scary experience for patients - particularly for those individuals who don't even know they have diabetes, so therefore have absolutely no idea what's going on. I'm very glad you recovered, and hope you are doing well!

[@Lemonz1989]

Thank you. :) I'm doing very well now. My diabetes is stable and I'm living a pretty normal life, with a few exceptions of course. :)

[@kcconsigo7429]

@@Lemonz1989 we have the same symptoms when i was diagnosed as type 2 diabetes, my potassium and blood pressure were low.

[@a.s.america]

Thank you so much for the material u provide to us. it really helps me in predental studies. I'm your fan now.

[@Wul-Lop]

Your lectures & videos inform & educate people around the world. ขอบคุณครับ (Thank you words in Thai).

[@HafizahHoshni]

Awesomely informative and perfectly explained! Thank you so much! 😊😊 15/9/2019

[@friendlyovertones]

Eric your 2 lectures on this subject are great. I am an Australian Nurse Academic and am trying to pass the NCLEx to practice in the USA. Your content is spot on with my experience but as I have noticed before and very sadly what they are teaching the nurses here in the USA is not very accurate. The RNs and Drs are not on the same page. Fortunately the NCLEX is so general that I can't get it wrong on this subject but learning for a test can be a bother when its not consistent with the clinical area and I am happy to see you pointed that out. You might want to look at the NCLEX lectures on this...you'll cry!

[@lynlynn2564]

Did you passed?

[@ahangrasheed4422]

this is great thank you so much D.Eric

[@user-lb1uw3hw5z]

What a genius! Thank you

[@StrongMed]

@pgcudahy: The best answer is probably that positive serum ketones is not super specific for DKA, as you can also get elevated serum ketones in "starvation ketoacidosis" (which doesn't actually require starvation per se), as well as alcoholic ketoacidosis. Labs used to report serum ketones as a dilution factor (i.e. ketones positive at 1:128, etc...), which would theoretically allow for better assessment of specificities, however, stopped doing so because physicians were overrelying on trends.

[@pgcudahy]

Any idea how specific a positive serum ketone is for DKA in anion gap acidosis? A few times I've been working up an anion gap acidosis and had a positive ketone result but still thought an alternative etiology more likely. It's resulted as a binary positive/negative rather than quantitative so I assume they set the cut-off for more sensitivity rather than specificity.

[@myrzakhanmustapayev2401]

thank you!

[@topleaseyou7300]

What's the song in the background?

[@Henipah]

Point of care capillary ketone strips now measure b hydroxybutyrate, I base a lot of my management on serial ketone measurements.

[@allseriousness]

These days beta-hydroxybutyrate is a faster test often ran in the ED.

[@Introvertdoc]

Why there is increase creatinine in case of honk

[@kethvuthy445]

why in HHS glycemia is higher than DKA but no ketone ?

[@minwiggle8684]

Because usually HHS is associated with T2DM where there will still be getting insulin into cells, while DKA is usually associated with T1DM - there is zero insulin so zero getting into cells, therefore zero energy and so the body attempts to metabolize fatty acids for energy, leading to ketones. Severe HHS can also develop ketones if the insulin levels in the blood are low enough, but this is not typical.

[@maxlichtenberger7447]

To which statistic are you referring to if you are saying that dka is more common in type 2 diabetics in absolute numbers? Regards

[@StrongMed]

Thanks for bringing up an apparent error on my part. This video was from 10 years and 3 computers ago, and I honestly do not recall the source for that statement. My first year of videos were relatively sloppy, and I've gradually been retiring some of them (i.e. switching them to "unlisted" status) as I replace them with more up-to-date and accurate revisions (with better sound). Coincidentally, I am working on a new DKA video right now and the studies I've been reading indicate the majority of DKA admissions are type 1 diabetics. jamanetwork.com/journals/jamainternalmedicine/fullarticle/217393 pubmed.ncbi.nlm.nih.gov/18644074/ However, a significant minority of DKA patients do have type 2 - which may be a more common presentation in Black Americans: pubmed.ncbi.nlm.nih.gov/28534682/ There are a few other parts of this video (including part 2) that are outdated (e.g. beta hydroxybutyrate measurements are now a standard part of the initial evaluation in the US). I plan to retire these too once the replacement video is up in the next 1-2 weeks.

[@maxlichtenberger7447]

Except for that it was an excellent video about dka :) Thank you and looking forward to new content

[@ragulsen1512]

Sir hyperglycemia itself would cause a hyperosmolar state ryr

[@Shivmegaa]

❤

[@thetruth8225]

Voice !!! :)

[@pramodthapa2517]

Doc very low sound