Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycemic State (HHS)

Resuscitation Quick Ribbon (First 2 Minutes)

Fluid Resuscitation:1000–1500 mL Lactated Ringer's in hour 1, then 500–1000 mL/h for hours 2–4

Potassium Checkpoint:If K < 3.3 mEq/L: HOLD insulin; give 20–40 mEq/h K until K > 3.3 mEq/L

Regular Insulin:0.14 units/kg/h continuous infusion (no bolus required); reduce to 0.05 u/kg/h once BG < 200

Add Dextrose:Switch fluids to D5W + 1/2NS once glucose reaches < 250 mg/dL to prevent hypoglycemia

Pediatric Cerebral Edema:Headache, bradycardia, lethargy: give 3% Saline 3–5 mL/kg over 15m or Mannitol 0.5–1 g/kg

Bottom-Line Clinical Pearl

In DKA, the glucose is a symptom; the ketoacidosis is the disease. NEVER start insulin until the serum potassium is verified to be > 3.3 mEq/L. Starting insulin in severe hypokalemia drives potassium into cells and triggers fatal ventricular arrhythmias. Fluid resuscitation is the cornerstone: administer 1–2 L of balanced crystalloids in the first 2 hours. When blood glucose drops < 200–250 mg/dL, add Dextrose (5–10%) to fluids while continuing the insulin infusion to clear the anion gap.

1. DKA vs. HHS Diagnostic Comparison

Parameter	Diabetic Ketoacidosis (DKA)	Hyperosmolar Hyperglycemic State (HHS)
Blood Glucose	Usually 250–600 mg/dL	Profoundly elevated: > 600–1000+ mg/dL
Arterial / Venous pH	Acidemic: < 7.30 (severe < 7.00)	Normal or mild: > 7.30
Serum Bicarbonate	Low: < 18 mEq/L (severe < 10 mEq/L)	Normal or mild reduction: > 18 mEq/L
Serum Ketones	Positive (Beta-hydroxybutyrate > 3.0 mmol/L)	Negative or weakly positive
Effective Serum Osmolality	Variable (< 320 mOsm/kg)	Profoundly hyperosmolar: > 320 mOsm/kg
Mental Status	Alert to drowsy	Stupor, coma, profound lethargy, seizures
Fluid Deficit	Average 5–7 Liters (100 mL/kg)	Massive: 8–12 Liters (150–200 mL/kg)