4.

Question 1

What type of patients get DKA and what type of patients get Hyperosmolar Hyperglycaemic State (HSS)?

Answer 1

DKA in type 1 diabetes

HSS in type 2 diabetes

Question 2

Diagnostic results in DKA

Answer 2

• hyperglycaemia BM often >30 mmol/L
• keto (urine for ketone levels or ketometer)
• Acidosis + watch for increased K+

Question 3

Diagnostic levels for Hyperosmolar Hyperglycasemis state (HHS)

Answer 3

• hyperglycaemia (usually >35 mmol/L)
• osmolarity >340 mmol/L (calculated by (x2 Na + x2 K) + urea + glucose
• nonkeroric (no ketones in urine or blood)

Question 4

How to calculate hyperosmolarity in HSS?

Answer 4

(x2 Na + x2 K+) + urea + glucose

* in HSS is over 340 mmol/L

Question 5

Management of DKA

Answer 5

• ABC
• IV fluid: 1 L normal saline STAT -> then 1 L over 1 hour -> then over 2 hours -> then over 4 hours -> then over 8 hours
• Fixed-rate insulin e.g. ActRapid in 50 ml 0.9% saline at 0.1 units/kg/hour

Question 6

Monitoring of patient in DKA

Answer 6

• BM and ketones hourly
• repeat VBG 2 hourly
• potassium monitoring

Question 7

Ketones or bicarbonate aims in treatment of DKA

Answer 7

Aim to:

• decrease ketones by >0.5 mmol/L/h

OR

• increase bicarbonate by > 3mmol/L/h

If not: increase the rate of insulin by 1 unit/h until target is achieved

Question 8

Potassium ranges/monitoring in DKA management

Answer 8

• >5.5 mmol/L add no potassium to noram saline
• 4-5.5 mmol/L - add 20 mmol KCl
• <4 mmol/L - add 40 mmol KCl

Question 9

What to do if glucose is <14 mmol/L in DKA management?

Answer 9

Add 10% dextrose at 125ml/h to prevent hypoglycaemia

Question 10

What can trigger DKA?

Answer 10

• missed insulin
• infection
• MI

Question 11

Management of AKI

Answer 11

• cannula
• catheter
• strict fluid monitoring
• IV fluid 500 mL stat then 1 L 4 hourly
• monitor U&Es and fluid balance

Question 12

Management of hypoglycaemia if patient is able to eat

Answer 12

sugar-rich snack e.g. orange juice + biscuits

Question 13

Management of hypoglycaemia if a patient is unable to eat e.g. drowsy/vomiting

Answer 13

• IV glucose via cannula e.g. 100mL 20% glucose
• if no cannula: give 1 mg IM glucagon

Question 14

When to treat hypertension?

Answer 14

• if BP >150/95
• >135/85 and any of the following present:
• age >80 and BP in clinic >150/90
• age <80 and end-organ damage, CVS or renal disease or 10-year CVD risk >/10%
• age <60 and CVD risk <10%

Question 15

Aim BP values for patients <80 y/o

Aim if >80

Answer 15

• <140/90 in the clinic
• <135/85 at home

*if >80 then add 10 mmHg to above systolic values

Question 16

Chronic HF management

Answer 16

• ACE inhibitor + beta-blocker
• if intolerant to ACE inhibitor use angiotensin II receptor antagonist (e.g. candesartan)
• If intolerant to ARB: use hydralazine or nitrate

*if inadequate: increase doses as tolerated

*if still inadequate: add aldosterone receptor antagonist (e.g. spironolactone)

*if still inadequate: specialist reassessment to consider sacubitril valsartan, digoxin, ivabradine or resynchronization therapy

Question 17

When to use Flecainide and when Amiodarone in treatment of AF (if suitable)

Answer 17

• Flecainide: if no structural heart disease
• Amiodarone: if the structural heart disease

Question 18

Rate control in AF - what medications used?

Answer 18

Monotherapy with either of:

• beta-blocker e.g. bisoprolol 2.5mg daily
• rate-limiting CCB e.g. diltiazem 120 mg daily

If monotherapy doesn’t control symptoms: consider combination therapy with any 2 of the following:

beta-blocker, diltiazem or digoxin

Question 19

Can amiodarone be used for long-term rate control?

Answer 19

No

Question 20

When can we consider digoxin monotherapy in AF?

Answer 20

• non paroxysmal AF if a person is sedentary