35-36: Management of DKA/HHS

Question 1

Diabetic emergrncies definition

Answer 1

Hyperglycemic states caused by severe insulin deficiencies (both endogenous and exogenous)

Question 2

Diabetic Ketoacidosis (DKA)

Answer 2

Hyperglycemia
Hyperketonemia
Metabolic Acidosis

Question 3

Hyperglycemic Hyperosmolar State (HHS)

Answer 3

Severe Hyperglycemia
Hyperosmolality
Severe fluid depletion

Question 4

Life-threating conditions

Answer 4

Leading cause of death in kids with T1DM

Question 5

Pathogenesis of diabetic emergencies

Answer 5

Reduction in the net effective action of circulating insulin

Elevation of counterregulatory hormones (Glucagon, catecholamines, cortisol and growth hormone)

Question 6

DKA usually occurs in

Answer 6

T1DM

Question 7

Precipitating factors to DKA

Answer 7

Poor adherence to treatment regimen
Infection or illness

Question 8

Drugs contributing to DKA

Answer 8

Thiazides
Steroids
Sympathomimetics
Atypical Antipsychotics
SGLT-2 inhibitors

Question 9

Clinical Presentation of DKA

Answer 9

Poly symptoms
Nausea/vomiting
Abdominal pain
Changes in mental status
Fruity breath
Coma

Question 10

Severe DKA Classification

Answer 10

Plasma glucose: (mg/dL): >250

Arterial pH: <7.00

Serum bicarb: <10

Urine and serum ketone; Positive

Serum Osmolality: Variable

Anion gap: >12

Mental status: Stupor/Coma

Question 11

DKA diagnosis triad

Answer 11

HYPERglycemia
HYPERketonemia
Metabolic Acidosis

Question 12

DKA: Goals of Tx

Answer 12

Restore circulatory volume
Fluids

Inhibit ketogenesis and return of normal glucose metabolism
-Insulin

Correct electrolyte imbalance
Supplement electrolytes

Question 13

Fluid Management

Answer 13

First Step
Administer 0.9% NS of 500-1,000mL/hr for first 1-4 hours

Evaluate corrected Na+ at 2-4 hours

Corrected Na normal/high: Change to 1/2 NS and Drop the rate by 50%
Corrected Na low: Continue NS and drop the rate by 50%

When BG approaches 200mg/dL, change to D5W w/0.45% NS at 150-300mL/hr until resolution of ketoacidosis

Corrected sodium = measured sodium + 1.6 [(glucose-100/100)]

Question 14

Balanced Crystalloids (LR, Plasma-Lyte, Normasol)

Answer 14

Recent data suggesting that NS should not be used in acidosis due to excess chloride content worsening acidosis

Emerging studies showing possible reduction in time to DKA resolution when using balanced crystalloids vs NS
-May also reduce AKI

Question 15

Insulin

Answer 15

Second step in the management of DKS after fluids are started
-Can be admin IV, SQ, or I<
-IV continuous infusion preferred and most commonly used
-Requires level of care sufficient for hourly labs/blood glucose checks

Question 16

IV Insulin initiation

Answer 16

Start 0.1 units/kg/hour +/- a bolus of 0.1 units/kg
-Check glucoses every hour; most facilities will use a nursing protocol with an insulin drip

If glucoses do not fall by >10% (or 50-70 mg/dL) in first hour, perform, repeat or increase bolus dose (0.1-0.14 units/kg)

Question 17

IV insulin when plasma glucoses reach 200 mg/dL

Answer 17

DECREASE infusion rate to 0.02-0.05 units/kg/hour AND change fluids from NS to 1/2 NS + D5W