Acute Hyperglycemic Complications Exam 2 Flashcards
Pathyphysiology for DKA and HHS
- 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
What is the cause of hyperglycemia?
- increased gluconeogenesis
- accelerated glycogenolysis
- impaired glucose utilization
Explain the ketoacidosis in DKA
- Release of free fatty acids (lipolysis) - Hepatic fatty acid oxidation (ketones) - Metabolic acidosis and Ketonemia
What are the ketones?
- Beta-hydroxybutyrate - main metabolic product (esp when testing for ketones)
- Acetoacetate
- Acetone
Endogenous insulin role in HHS
Adequate enough to prevent lipolysis and ketogenesis
Clinical presentation of DKA and HHS
- Hyperglycemia
- Polyuria
- Polydipsia
- Polyphagia
- Weight loss
- Nausea / Vomiting
- Dehydration
- Poor skin turgor
- Weakness
- Mental status changes
- Tachycardia
- Hypotension
Clinical presentation of DKA only
- Rapid onset
- High ketones
- Kussmaul respirations
- Fruity breath odor (acetone)
- Abdominal pain
Clinical presentation of HHS only
- Onset over several days to weeks
- Mild or no ketones
- Seizures
Glucose lab findings for DKA
> 250 mg/dL
Serum bicarbonate lab findings for DKA
- Mild: 15-18
- Moderate: 10 - 14
- Severe: < 10
pH for DKA
- Mild: 7.25 – 7.30
- Moderate: 7.00 - 7.24
- Severe: < 7.00
Glucose lab findings for HHS
> 600 mg/dL
Serum bicarbonatelab findings for HHS
> 15
Sodium
- 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
Potassium
- 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
Phosphate
- Normal or elevated due to intracellular phosphate moving to extracellular space during insulin deficiency and hypertonicity
- Normal values 2.1-4.3mg/dL
Osmolality
- 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
Effective serum osmolality for DKA
- Typically normal
- Normal values 270-290 mOsm/kg
pH for HHS
> 7.30
ketone lab finding for HHS
Small or negative
Effective serum osmolality for HHS
> 320 mOsm/kg
Mental status for HHS
Stupor / coma
Anion gap
- Normal is between 7 – 9 mEq/L
- The larger the anion gap the more severe the acidosis
Anion gap values for DKA
- Mild: >10
- Moderate: >12
- Severe: >12
Anion gap values for HHS
Variable
Monitoring parameters
- Electrolytes
- BUN
- pH
- Creatinine every 2-4 hours
- Glucose every 1-2 hours
- Urine output
IV fluid replacement
- restore renal perfusion
- increase urine output
- expansion of intravascular, interstitial, and intracellular volume and hydration
Insulin resolution for DKA
- 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
Bicarb administration
- No data to support any benefit and several A/E including cerebral edema and decreased tissue oxygen uptake
- Consider when pH < 6.9
Phosphate administration
- Typically will normalize with insulin
- Consider in patients with cardiac dysfunction, anemia, or respiratory depression and phosphate levels < 1.0 mg/dL
criteria for resolution of DKA
- Blood glucose < 200 mg/dL AND (2 of the 3) - Bicarbonate ≥ 15 mEq/L - pH > 7.3 - Calculated anion gap ≤ 12 mEq/L
Insulin resolution for HHS
- 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
criteria for resolution of HHS
- Blood glucose < 300 mg/dL AND
- Normal osmolality < 315 mOsm/kg AND
- Normal mental status
acute complications of treatment
- 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
preventative measures
- 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
sick day management
- 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
