Diabetes Mellitus - DKA and HHS

Question 1

List 10 clinical features of diabetic ketoacidosis (DKA).

Answer 1

Drowsiness
Vomiting
Dehydration
Abdominal pain
Polyuria
Polydipsia
Lethargy
Ketotic breath
Coma
Kussmaul breathing (prolonged expiration)

Question 2

List the features of severe DKA. (5)

Answer 2

Blood ketones: 6+
Bicarbonate: <5
Blood pH: <7.1
Potassium: <2.5
Anion gap: 16+

Question 3

List 6 complications of DKA.

Answer 3

Cerebral oedema
Aspiration pneumonia
Hypokalaemia
Hypomagnesaemia
Hypophosphataemia
Thromboembolism

Question 4

List 7 precipitating factors for DKA.

Answer 4

Infection
Surgery
MI (other acute illness)
Pancreatitis
Chemotherapy
Anti-psychotics
Non-compliance with insulin

Question 5

Describe the pathophysiology of DKA. (4)

Answer 5

1. Absolute lack of insulin
   a. This causes counter-regulatory hormone release
2. This causes:
   a. Increased lipolysis
   b. Decreased glucose uptake
   c. Increased gluconeogenesis
   d. Increased glycogenolysis
3. All of these processes cause hyperglycaemia
   a. This leads to osmotic diuresis
   b. This leads to dehydration
   c. This leads to electrolyte imbalances
4. Increased lipolysis creates more free fatty acids (FFAs), which are used in ketogenesis
   a. Ketones are very acidic, and are buffered by bicarbonate
   b. When bicarbonate stores are used up, ketoacidosis develops

Question 6

What investigations would you do for DKA? (4)

Answer 6

Blood tests (including amylase, osmolality, blood cultures)
Urine
ECG
CXR

Question 7

How would you treat DKA? (6)

Answer 7

Saline (IV - at least 1L in first hour)

Insulin (infusion - add dextrose when glucose levels back to normal)

Potassium infusion (40mmol/L)

Low molecular weight heparin

Monitoring:

• Capillary blood glucose (1 hourly)
• U&Es
• Urine output

Treat cause of DKA

Question 8

Describe the symptoms of HHS. (7)

Answer 8

Altered mental status
Polyuria
Polydipsia
Weakness
Dehydration
Seizures
HONK (hyperosmolar, non-ketotic coma)

Question 9

List 6 complications of HHS.

Answer 9

Stroke
MI
Pulmonary embolism

Iatrogenic complications, e.g.

• Hypoglycaemia
• Hypokalaemia
• Cerebral oedema

Question 10

How would you manage HHS? (4)

Answer 10

Saline (IV - 1-2L over first hour)

Continuous insulin infusion (start when potassium is 3.5+)

Potassium infusion (start when patient is urinating again)

Low molecular weight heparin (LMWH)