Acute Hyperglycemic Complications Exam 2

Question 1

Pathyphysiology for DKA and HHS

Answer 1

• Decreased insulin causes hyperglycemia because cells cannot take up glucose
• This causes the body to think that it doesn’t have enough glucose
• Which activates counter-regulatory hormones
• Glucagon, catecholamines, cortisol, growth hormone

Question 2

What is the cause of hyperglycemia?

Answer 2

• increased gluconeogenesis
• accelerated glycogenolysis
• impaired glucose utilization

Question 3

Explain the ketoacidosis in DKA

Answer 3

- Release of free fatty acids
(lipolysis)
- Hepatic fatty acid
oxidation (ketones)
- Metabolic
acidosis and Ketonemia

Question 4

What are the ketones?

Answer 4

• Beta-hydroxybutyrate - main metabolic product (esp when testing for ketones)
• Acetoacetate
• Acetone

Question 5

Endogenous insulin role in HHS

Answer 5

Adequate enough to prevent lipolysis and ketogenesis

Question 6

Clinical presentation of DKA and HHS

Answer 6

• Hyperglycemia
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Nausea / Vomiting
• Dehydration
• Poor skin turgor
• Weakness
• Mental status changes
• Tachycardia
• Hypotension

Question 7

Clinical presentation of DKA only

Answer 7

• Rapid onset
• High ketones
• Kussmaul respirations
• Fruity breath odor (acetone)
• Abdominal pain

Question 8

Clinical presentation of HHS only

Answer 8

• Onset over several days to weeks
• Mild or no ketones
• Seizures

Question 9

Glucose lab findings for DKA

Answer 9

> 250 mg/dL

Question 10

Serum bicarbonate lab findings for DKA

Answer 10

• Mild: 15-18
• Moderate: 10 - 14
• Severe: < 10

Question 11

pH for DKA

Answer 11

• Mild: 7.25 – 7.30
• Moderate: 7.00 - 7.24
• Severe: < 7.00

Question 12

Glucose lab findings for HHS

Answer 12

> 600 mg/dL

Question 13

Serum bicarbonatelab findings for HHS

Answer 13

> 15

Question 14

Sodium

Answer 14

• Correct sodium first and then assess for sodium or water deficit severity
• Typically will be low in DKA
• Normal to high in HHS
• Normal sodium is 135-145 mEq/L

Question 15

Potassium

Answer 15

• Most patients will have elevated levels due to the acidotic condition
• Normal 3.5 – 5.2 mEq/L
• Low < 3.3mEq/L
• High > 5.2mEq/L

Question 16

Phosphate

Answer 16

• Normal or elevated due to intracellular phosphate moving to extracellular space during insulin deficiency and hypertonicity
• Normal values 2.1-4.3mg/dL

Question 17

Osmolality

Answer 17

• Normal values 270-290 mOsm/kg
• Low = higher amount of water in relation to dissolved particles and you have overhydration
• High = deficient fluid volume and dehydration

Question 18

Effective serum osmolality for DKA

Answer 18

• Typically normal

- Normal values 270-290 mOsm/kg

Question 19

pH for HHS

Answer 19

> 7.30

Question 20

ketone lab finding for HHS

Answer 20

Small or negative

Question 21

Effective serum osmolality for HHS

Answer 21

> 320 mOsm/kg

Question 22

Mental status for HHS

Answer 22

Stupor / coma

Question 23

Anion gap

Answer 23

• Normal is between 7 – 9 mEq/L

- The larger the anion gap the more severe the acidosis

Question 24

Anion gap values for DKA

Answer 24

• Mild: >10
• Moderate: >12
• Severe: >12

Question 25

Anion gap values for HHS

Answer 25

Variable

Question 26

Monitoring parameters

Answer 26

• Electrolytes
• BUN
• pH
• Creatinine every 2-4 hours
• Glucose every 1-2 hours
• Urine output

Question 27

IV fluid replacement

Answer 27

• restore renal perfusion
• increase urine output
• expansion of intravascular, interstitial, and intracellular volume and hydration

Question 28

Insulin resolution for DKA

Answer 28

• Keep glucose between 150-200 mg/dL until resolution of DKA
• Once DKA resolves, continue IV insulin for 12 hours after initiating subcutaneous therapy
• Initiate subcutaneous therapy at doses patient was taking prior to DKA OR at 0.5 to 0.8 units/kg/day

Question 29

Bicarb administration

Answer 29

• No data to support any benefit and several A/E including cerebral edema and decreased tissue oxygen uptake
• Consider when pH < 6.9

Question 30

Phosphate administration

Answer 30

• Typically will normalize with insulin

- Consider in patients with cardiac dysfunction, anemia, or respiratory depression and phosphate levels < 1.0 mg/dL

Question 31

criteria for resolution of DKA

Answer 31

- Blood glucose < 200 mg/dL 
AND (2 of the 3)
- Bicarbonate ≥ 15 mEq/L 
- pH > 7.3 
- Calculated anion gap ≤ 12 mEq/L

Question 32

Insulin resolution for HHS

Answer 32

• Keep glucose between 200-300 mg/dL until resolution of HHS
• Continue IV insulin for 1-2 hours after initiating subcutaneous therapy
• Initiate subcutaneous therapy at doses patient was taking prior to HHS OR at 0.5 to 0.8 units/kg/day

Question 33

criteria for resolution of HHS

Answer 33

• Blood glucose < 300 mg/dL AND
• Normal osmolality < 315 mOsm/kg AND
• Normal mental status

Question 34

acute complications of treatment

Answer 34

• Hypoglycemia - Overly aggressive insulin therapy
• Hypokalemia - Overly aggressive insulin therapy - Not replacing potassium
• Hyperglycemia - Insulin stopped too early
• Cerebral edema - Plasma osmolality decreases too quickly

Question 35

preventative measures

Answer 35

• Patient education
• Routine monitoring of ketones when BG >300mg/dL ; Ketostix
• Psychological assistance for underlying eating disorders or stressful family dynamics
• Financial assistance for medications and supplies
• Sick day management protocols

Question 36

sick day management

Answer 36

• continue taking DM meds
• know when to contact dr
• SMBG q2h
• ketone monitor q2 h
• know what to do when ketones are present (?)
• have anti-emetic med