Both diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are usually triggered by a precipitating cause: infection, infarction, infant on board (pregnancy), dietary indiscretion, and insulin deficiency. (The “five Is.”)
In DKA, the pH is typically < 7.3, anion gap > 10, serum bicarbonate < 18 mEq/L, and with both elevated urine and serum ketones.
In HHS there is typically no ketosis and a normal anion gap, but serum osmolality > 320 mOsm/kg.
In most adult cases of DKA, fluid deficit is estimated to be 3 to 6 L; in HHS, the deficit is 9 to 12 L.
Provide volume resuscitation before starting insulin therapy, as it will decrease hyperglycemia 35 to 70 mg/dL, even without insulin.