Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS): Comparison (Nursing)

00:00 Students often find understanding the difference between HHNS and DKA to be a bit challenging, but I promise you it really isn't.

00:09 So in this discussion, we're going to compare and contrast HHNS, which is hyperosmolar hyperglycemic nonketotic syndrome, and DKA, which is diabetic ketoacidosis.

00:23 So let's get rolling.

00:25 Now HHNS and DKA are both serious complications of diabetes.

00:30 So you're going to see a lot of things that are similar between these two, but also there's some very distinct things that are different because they do differ in several important ways.

00:40 And here's where we're going to begin the comparison.

00:42 Let's start with what they have in common.

00:44 Now both involve severely elevated blood glucose levels, so they both will have hyperglycemia.

00:49 Remember, unless the DKA patient is on one of those special medications, they can be euglycemic, but usually the patient, both of them involve a severely elevated blood glucose or hyperglycemia.

01:03 Both lead to dehydration and electrolyte imbalances.

01:06 All right, so we've got what they've got in common.

01:09 Both are medical emergencies and they require immediate treatment and both typically require hospitalization.

01:16 So whenever you're studying, a great place to start is where is the things that are the same? How are they alike? So the first one, high glucose, they're going to be dehydrated and have some electrolyte imbalances.

01:28 They're medical emergencies.

01:29 They need treatment and it will typically need to be admitted to a hospital.

01:34 Now I want to look at the key differences and I'm going to do it factor by factor.

01:38 First, we're going to start with the patient population.

01:41 DKA primarily affects people with type 1 diabetes, though it can occur in type 2, but primarily it's going to be clients who've been diagnosed with type 1 diabetes.

01:52 HHNS almost exclusively affects people with type 2 diabetes and typically older adults.

01:58 Okay, so that's our first difference.

02:00 DKA primarily happens with type 1 diabetics.

02:03 HHNS primarily with type 2 diabetics and typically older adults.

02:08 Now what about the onset? How long does it take to develop? Well, DKA is rapid, usually in hours to days.

02:15 It can happen really fast compared to HHNS develops more gradually.

02:21 This can be days to weeks, so this may be harder for the patient to realize that it's happening.

02:27 Now when it comes to blood glucose levels, DKA is typically between 250 to 600.

02:33 HHNS is also often extremely high, frequently greater than 600 and sometimes greater than 1,000.

02:40 Okay, whoa, did you expect that? So the blood glucose levels of HHNS can actually be higher than DKA.

02:49 So how I try to remember that is like, well, the DKA happens real fast, but HHNS develops over a period of time, so that helps me remember that's why they can get to higher blood glucose levels.

03:01 Now that's not based in pathophysiology, that's just based in trying to remember and keep these things straight.

03:06 Now what about insulin status? Well, in DKA, they have a really severe insulin deficiency.

03:13 Whatever got them there, they don't have enough insulin to use the glucose that's in their bloodstream.

03:19 With HHNS, they have some insulin present, but also it's not enough for them relative to what they need.

03:26 So DKA is going to have a much more severe insulin deficiency without the medication compared to HHNS.

03:34 What about ketones? Well, diabetic ketoacidosis seems to have that right in the name.

03:39 HHNS does not have a K and therefore does not have the ketones.

03:44 DKA has significant ketone production and they end up in ketoacidosis.

03:50 Because of all those ketones in their bloodstream, their pH becomes more acidotic.

03:54 HHNS has minimal to no ketone production, that's why it's often called nonketotic.

04:01 So DKA has ketones, HHNS does not.

04:07 That's easy to remember because there's no K in HHNS, so that should be helpful.

04:12 Now, acidosis, definitely DKA, right? DKA is metabolic acidosis and they can often have a pH lower than 7.3.

04:21 HHNS usually has no significant acidosis, they don't have all those ketones building up.

04:27 So DKA, you'll see an acidotic pH.

04:30 HHNS usually doesn't have significant acidosis and they don't have all those ketones in their bloodstream.

04:36 What about dehydration? While DKA can have moderate dehydration, an average of about 6% of their body weight is lower.

04:44 HHNS has more severe dehydration, they're usually an average of 9% of their body weight.

04:51 So when it comes to being dehydrated, remember DKA comes on quick, but its dehydration is worse in HHNS as it develops over a longer period of time.

05:00 Now, the mortality rate for DKA is about 1-5%.

05:04 It's still higher than we would want, but it's about 1-5%.

05:09 Look at the mortality rate for HHNS, 10-20%.

05:14 Now it's higher for a couple reasons, mostly because we see this often in older patient population who may have other comorbidities.

05:21 Also the patient may not receive care as quickly because this develops over a longer period of time.

05:27 So, DKA 1-5%, HHNS 10-20% because this often involves older patients and they have multiple comorbidities or other illnesses.

05:39 So what throws someone into DKA or HHNS? Well for DKA, we know it's infection, they didn't get an insulin dose they needed, or they didn't know they were diabetic.

05:49 For HHNS, this can be an infection.

05:52 So a type 2 diabetic can have an infection they may or may not know about, this can cause them to go into HHNS.

05:59 Same thing that puts the body into stress, like something like a stroke.

06:04 Also medication noncompliance, if they, for whatever reason, again we don't judge, but for whatever reason, they are not taking the medication as it was prescribed, they can also develop HHNS.

06:15 And then one other thing that you may not have thought of is if the patient doesn't have access to water.

06:21 If they are not drinking enough water or they can't get water, this also puts them at an increased risk to develop HHNS.

06:29 Now how do we treat it? Well DKA, insulin therapy, remember if their potassium level is okay, we're going to start that insulin therapy, we're going to replace fluids, and we're going to correct the electrolytes.

06:38 And we do that right away.

06:41 With HHNS, because this is a little bit different situation, fluid replacement is our first priority.

06:48 Then we'll address the insulin and the electrolyte management.

06:51 So DKA, we're kind of going after that blood sugar as long as the potassium is okay, and then dealing with the fluid volume and the electrolyte correction, and HHNS, fluid replacement is our first priority.

07:04 Then we deal with the insulin, dealing with the blood sugar, and the electrolyte management.

07:08 Now both DKA and HHNS are conditions that will require careful monitoring and management of the complications, but it's your understanding of these differences that will help you recognize important cues, be able to analyze these cues, and provide safe care for your patients.

07:25 Hey, here's an extra bonus.

07:27 We created this chart for you because we want to help you study, but I also want to tell you how you can best use this so you recall this information when you need it on an exam or inpatient care.

07:37 So this is a comparison chart.

07:39 It's also a good way for you to take notes when you're going through things, but I would use this chart to study with a friend.

07:45 Anyone can put their finger on just one random symptom on the left-hand side, and then they should have to be able to tell you what that's like in DKA or HHNS.

07:56 You can also just pick a symptom randomly, put your finger on it, and you have to explain why that develops that way in HHNS or DKA.

08:05 So there are some ways that you can quiz each other.

08:07 The research tells us that the best way to study so that you can get things into your long-term memory and have them accessible when you want to take a test is to ask questions.

08:17 You can also get your family members involved working with you, but asking each other questions, asking yourself questions, is shown to be far superior than highlighting or rereading.

08:28 Those are the types of things you need to do to make sure this information is locked in and you can be successful in school.