Acute hyperglycemia

Question 1

What are the metabolic complications of DKA?

Answer 1

dehydration, ketosis, lyte imbalance, and acidosis

Question 2

What happens during DKA?

Answer 2

Too little insulin to transport glucose into cells that glucose accumulates in blood, raising levels 250 mg/dL or higher

Question 3

What is Hyperosmolar hyperglycemic state (HHS)?

Answer 3

When hyperglycemia and dehydration exacerbate each other until both are extreme. Glucose levels often rise > 600 mg/dL, though few (if any) ketones are present.

Question 4

Who does HHS current occur in?

Answer 4

Undiagnosed or older adults with DM2. More life threatening then DKA

Question 5

What is euglyemic ketoacidosis?

Answer 5

Associated w/ use of gliflozin (SGLT-2 meds) when the glucose may be minimally elevated, if at all. Felt to be d/t concomitant dehydration and/or lack of kcal ingestion

Question 6

True or false: DKA can occur in type 2 DM

Answer 6

True; more common in DM1, but can occur in DM2 during acute illness and/or after they have become insulin deficient

Question 7

What is ketosis?

Answer 7

A homestatic mechanism to feed cells when glucose can not enter cells. The body breaks down fat (lipolysis) into glucose and ketone bodies. As concentration of ketones increases, the kidneys excrete both glucose and ketones via osmotic diuresis causing dehydration and hyperglycemia

Question 8

True of false: Persons with DM benefit form having sick day management info reinforced over and over again during appts

Answer 8

True

Question 9

What are some sick day management stratagies a person with DM1 or 2 should follow?

Answer 9

• 8 oz fluid/hr; type depends on BG level
• test BG 2-4 hrs while BG elevated or until symptoms resolve
• test ketones every 4 hours or until - (type 1, depends for type 2)
• Cont meds as able. Adjust insulin to correct hyperglycemia, do not stop/hold insulin if DM1. Hold Metformin during serious illness
• Consume 150-200 g CHO daily in divided doses
• Educate on when to call MD (persistent V/D, glu >300 on 2 consecutive measures that are not responsive to insulin)
• Call MD if mod to large urine blood/urine ketones >10.8 mg/dL

Question 10

What are the arterial pH, bicarb, and anion cap of someone in DKA?

Answer 10

Arterial pH: < 7.3
Serum bicarb: <16 mEq/L
Anion gap: > 15

Question 11

What are the steps to treating DKA?

Answer 11

1. Provide fluids to rehydrate
2. Provide adequate insulin to restore/maintain normal glucose metabolism
   3 . Correct lyte abnormalities/acidosis
3. Provide source of glucose when needed
   5 Preven complications
4. Provide education and follow up for pt/family

Question 12

During treatment of DKA, how much fluid replacement is needed?

Answer 12

Adults: 1-2 L in the first hr, than reassess status
Children: 10-20 mL per kg of body weight in first hour. If not urination, cont 20 mL per kg of body wt during 2nd and 3rd hours

1/2 (0.45%) or normal (0.9%) saline used, depending on serum sodium and state of hydration

Hydration status should correct w/in 48 hours

Question 13

What type of insulin should be provided to a patient during DKA?

Answer 13

Regular insulin by continuous IV infusion (d/t more predictable decreases in glucose and reduced risk of cerebral edema)

Question 14

In treating DKA, once urine output is documented (depending on serum K+ level), _____ of potassium per L of fluid may be infused

Answer 14

20 to 30 mEq; K+ should be frequently monitored q 2-4 hours

Question 15

True or false: Research supports routine supplementation of serum phos during DKA

Answer 15

False; research does not support routine supplementation, as oral intake can promptly replace deficits

Question 16

Why should sodium bicarb be used with caution in treating DKA?

Answer 16

No clinical benefit, increases risk for hypokalemic arrhythmias b/c it causes K+ to drop quickly, may increase risk for cerebral edema

Question 17

True or false: when treating DKA, when glucose reaches 250 mg/dL, 5-10% dextrose is added to the IV solution

Answer 17

True; to prevent cellular starvation and cerebral edema

Question 18

A minimum of ___ overlap between infused insulin and initiation of subq basal insulin helps avoid gaps in insulin delivery

Answer 18

2 hour

Question 19

For mild DKA being treated at home, how should insulin doses be adjusted to compensate for hyperglycemia and ketosis?

Answer 19

4 to 10 units or 10-20% of the usual TDD. Monitor frequently and adjust insulin for slow drop in glucose and resolution of ketosis

Question 20

Within how many days does HHS typically develop?

Answer 20

12 days (develops slowly)

Mortality rate is about 15% higher than rate for DKA due to higher rate of misdiagnosis

Question 21

When blood glucose levels exceed ___ mg/dL, the kidneys are no longer able to reabsorb glucose

Answer 21

180 mg/dL

Question 22

What are the primary markers of HHS?

Answer 22

Severe hyperglycemia, profound dehydration, neuro changes, and absence of signifiant ketosis

Question 23

Blood glucose levels in HHS are typically > ____ mg/dL

Answer 23

600 mg/dL (mean reported >1000 mg/dL)

Question 24

Profound dehydration is marked by plasma osmolality > ____ mOsm per kg

Answer 24

320 (deficits of 20-25% total body water may be observed)

Question 25

What are the treatment goals for HHS?

Answer 25

1. Provide adequate fluids to rehydrate
2. Correct lytes
3. Provide adequate insulin to maintain normal glucose metabolism
4. Prevent complications
5. Treat underlying condition

Question 26

How should fluids be replaced in a patient with HHS?

Answer 26

Infuse 1/2 of fluid deficient over 12 hours and the remainder during the following 12-24 hours.

Glucose may drop as much as 80-200 mg/dL per hour from rehydration alone

Question 27

What is the calculation for corrected Na?

Answer 27

Corrected Na+ = [Na+ 0.016 x (serum glucose-100]

Question 28

Measures for _____ can help diagnose DKA and monitor progress

Answer 28

Beta-hydroxybutyrate

Question 29

What medical conditions/situations might cause ketoacidosis without DKA?

Answer 29

starvation and alcoholic ketoacidosis