Diabetic Ketoacidosis (DKA) - Hyper___ - Hyper___ - metabolic ___

- hyperglycemia - hyperketonemia - acidosis

hyperglycemic hyperosmolar state (HHS) - ___ hyperglycemia - hyper___ - severe ___ depletion

- severe - hyperosmolality - fluid typically dont see ketoacidosis

DKA Background - usually occurs in type ___ - leading precipitating factors: poor adherence and ___

- T1DM - infection leading cause of mortality in children with T1DM

DKA Goals of Treatment - restore ___ volume ( ___ ) - inhibit ___ and return of normal glucose metabolism ( ___ ) - correct ___ imbalances ( supplement ___ )

- circulatory, fluids - ketogenesis, insulin - electrolyte, electrolytes

DKA Fluids - NS at ___ mL/hr for first 1-4 hours - evaluate corrected ___ at 2-4 hours - when corrected Na is normal/high, change to ___ NS and decrease rate by ___ % - when corrected Na low: continue NS and decrease rate by ___ % - when BG approaches ___ mg/dL, change to ___ with 1/2 NS at ___ mL/hr until resolution of ketoacidosis

- 500-1000 mL/hr - Na - 1/2, 50% - 50% - 200 mg/dL, D5W, 150-250 mL/hr

DKA: IV insulin - start ___ units/kg/hours w/wo a bolus of ___ units/kg - check glucose ___ - if glucose does not fall by >/= ___ % ( or ___ - ___ mg/dL) in first hour, repeat, or increase bolus dose ( ___ - ___ units/kg)

- 0.1, 0.1 - hourly - 10%, 50-70 mg/dL - 0.1-0.14 units/kg

DKA: IV Insulin - fluids restore renal ___ , normal ___ , and volume status - excreting ___ and ___, restoring electrolyte balance - insulin is restoring normal ___ process (inhibiting ___ , stopping ___ , reducing ___ )

- perfusion, osmolality - glucose, ketoacids - glycemic, glucagon, lipolysis, hyperosmolarity

DKA: SQ Insulin transitioning to SubQ insulin from IV when: - BG ___ pt should not be ___

- 200 mg/dL - 12 - 15 - 7.3 - NPO

Diabetic Emergencies Flashcards by Reagan Smith

Diabetic Emergencies - ___ states caused by severe insulin deficiencies (both ___ and ___ )
- diabetic ___
- hyperglycemic ___ state

hyperglycemic
endogenous
exogenous
ketoacidosis
hyperosmolar

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Diabetic Ketoacidosis (DKA)

Hyper___
Hyper___
metabolic ___

hyperglycemia
hyperketonemia
acidosis

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hyperglycemic hyperosmolar state (HHS)

___ hyperglycemia
hyper___
severe ___ depletion

severe
hyperosmolality
fluid

typically dont see ketoacidosis

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DKA Background

usually occurs in type ___
leading precipitating factors: poor adherence and ___

T1DM
infection

leading cause of mortality in children with T1DM

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DKA Background

Drugs that can cause DKA

thiazides
steroids
sympathomimetics
atypical antipsychostics
SGLT-2 inhibitors

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DKA Symptoms

2 most common symptoms: ___ and ___ pain
- polyuria, polydipsia, weight loss, dehydration
- changes in ___ status
- ___ breath (acetone)
- ___ respirations
- Coma

N/V, abdominal
- mental
- fruity
- Kussmaul

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DKA Goals of Treatment

restore ___ volume ( ___ )
inhibit ___ and return of normal glucose metabolism ( ___ )
correct ___ imbalances ( supplement ___ )

circulatory, fluids
ketogenesis, insulin
electrolyte, electrolytes

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DKA Fluids

NS at ___ mL/hr for first 1-4 hours
evaluate corrected ___ at 2-4 hours
when corrected Na is normal/high, change to ___ NS and decrease rate by ___ %
when corrected Na low: continue NS and decrease rate by ___ %
when BG approaches ___ mg/dL, change to ___ with 1/2 NS at ___ mL/hr until resolution of ketoacidosis

500-1000 mL/hr
Na
1/2, 50%
50%
200 mg/dL, D5W, 150-250 mL/hr

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DKA: fluids

the case for balances crystalloids (LR, plasma-lyte, Normasol)

might resolve DKA quicker
less Cl (doesnt worsen acidosis)
may also reduce AKI

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DKA: insulin

second step in the management of DKA after fluids are initiated
- ___ continuous infusion preferred and most common
- requires ___ labs/BG checks

IV
hourly

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DKA: IV insulin

start ___ units/kg/hours w/wo a bolus of ___ units/kg
check glucose ___
if glucose does not fall by >/= ___ % ( or ___ - ___ mg/dL) in first hour, repeat, or increase bolus dose ( ___ - ___ units/kg)

0.1, 0.1
hourly
10%, 50-70 mg/dL
0.1-0.14 units/kg

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DKA: IV Insulin

fluids restore renal ___ , normal ___ , and volume status
excreting ___ and ___, restoring electrolyte balance
insulin is restoring normal ___ process (inhibiting ___ , stopping ___ , reducing ___ )

perfusion, osmolality
glucose, ketoacids
glycemic, glucagon, lipolysis, hyperosmolarity

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DKA: SQ Insulin

transitioning to SubQ insulin from IV when:
- BG < ___ mg/dL
have 2 or more of below:
- anion gap closes ___ mEq/L or greater
- bicarbonare level greater than or equal to ___ mEq/L
- venous pH > ___

pt should not be ___

200 mg/dL
12
15
7.3
NPO

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DKA: SQ Insulin

can restart home regimen or tweak it if it was working previously
OR consider ___ rapid acting insulin q 2 hrs at ___ units/kg
OR if insulin naive, start multidose regimen of ___ units/kg/d, divided ___ basal/bolus
OR consider adding up total amount of daily IV insulin and convert to basal/bolus or q6hr ___

SQ, 0.1
0.5-0.8, 50/50
NPH

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DKA: SQ Insulin - transitioninf from IV to SQ

Overlap IV and SubQ insulin by ___ hours to prevent rebound ketoacidosis or hyperglycemia

2-4

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DKA: Anion Gap

evaluates metabolic acidosis
___ charges minus ___ charges
a gap greater than or equal to ___ mEq/L suggests metabloic acidosis
when gap closes or becomes less than __, can begin to think about transition from IV to ___ insulin

positive, negative
12
12
SQ

Anion Gap equation

= Na - (chloride + bicarb)

HHS Background

___ adults and type ___
underlying ___ or ___ disease
precipitaing factors may include heart attack, stroke, infection, recent procedure
inadequate __ intake

older, II
HF, kidney
fluid

HHS Patho

insulin deficiency or ___
reduced utilization of glucose in ___ , muscle , and ___
massive amounts of ___ in urine
increased ___ loss / dehydration
poor perfused ___
decreased ability to clear excess ___ , leading to ___
mental confusion, coma, seizures

resistance
liver, fat
glucose
water
kidneys
glucose, hyperosmolality

HHS

why doesn’t the body convert to ketosis?
- reduced levels of ___ may play a role
- small amounts of endogenous ___ may be enough to restrain ketogenesis

growth hormone
insulin

HHS Symptoms

weakness (may occur over days to ___ )
- poly___
- poly___
- dehydration w/ reduced fluid intake
- lethargy

severe:
- confusion
- coma
- seizures

weeks
- polyuria
- polydipsia

T or F: the mechanism for both DKA and HHS is a reduction in circulating insulin coupled with elevation of counterregulatory hormones (glucagon, catecholamines, corticol, and growth hormone)

True

DKA Patho

non-adherence, infection, new diagnosis
increased counterregulatory hormones (opposes circulating ___ )
increased ___ glucose production, decreased peripheral insulin ___
lack of peripheral glucose ___
increased ___ in adipose tissue
triglycerides break down into glycerol and ___
FFAs break down into ___

insulin
hepatic, sensitivity
uptake
lipase
FFAs
ketones

DKA Triad

___ glycemia
___ ketonemia
metabolic ___

hyperglycemia
hyperketonemia
acidosis

# DKA: IV Insulin - when plasma glucose reaches 200 mg/dL, decrease infusion rate to ___ - ___ units/kg/hr AND - change fluids from NS to ___ and ___ and decrease rate to ___ - ___ mL/hr - - adjust rate of insulin or dextrose administration level of ___ - ___ mg/dL

- 0.02-0.05 units/kg/hr - 1/2 NS, D5W, 150-250 mL/hr - 150-200 mg/dL

# DKA: electrolytes and lab abnormalities electrolytes of concern (4) other pertinent labs (3)

- K, Na, PO4, anion gap - pH, SCr, WBC

# DKA - Potassium - maintain K or ___ - ___ mmol/L - do NOT start insulin if K < ___ mmol/L | increased

- 4-5 - 3.3

# DKA - Sodium - administer ___ at 500-1000 mL/hr for first 1-4 hrs - if corrected is high: change to ___ and decrease rate by ___ % - if corrected low: continue ___ and decrease rate by ___ % when blood glucose in ___ mg/dL, change to ___ with ___ at a rate of 150-250 mL/hr | decreased

- NS - 1/2 NS, 50% - NS, 50% - 200 mg/dL, D5W, 1/2NS

T or F: phosphate is typically not replaced in DKA

T; might be supplemented as potassium phosphate in fluids with < 1 mg/dL phos and comorbidities

# DKA - Bicarb - if pH is >/= 6.9 .... - if pH is < 6.9: give ___ - ___ mmol bicarb q1-2h until pH >/= 7

- No bicarb - 50-100

# Euglycemic DKA (rare) - pt has normal/slightly elevated glucose (200 mg/dL) - urine still + for ___ - may be caused by poor oral intake, pregnancy, or ___ inhibitors - may require more __earlier in therapy but treatment generally similar

- ketones - SGLT2 - dextrose

# HHS: Laboratory Findings - Glucose: ___ - ___ mg/dL - Sodium varies: often dilutional ___ vs severe dehydration leading to ___ - BUN: often severely elevated > ___ mg/dL - serum osmolality > ___ mOsm/kg

* 800-2400 * hyponatremia, hypernatremia * 100 * 320

# HHS: goals of treatmment - restore circulatory volume via ___ - restore urine output to __ mL/hr or more via - return BG to normal via ___ and ___

- fluids - fluids - fluids, insulin

# HHS: Fluids - administer ___ or ___ at 500-1000 mL/hr for first 1-4 hours - evaluate corrected ___ at 2-4 hrs - if corrected is high, reduce the ___ - if corrected is low, consider ___ - when BG is ___ mg/dL change to ___ with ___ at 150-250 mL/hr until resolution of HHS

* 1/2 NS, NS * Na * rate * NS * 300 * D5W, 1/2 NS

# HHS Insulin - start ___ units/kg/hour +/- a bolus of ___ units/kg - check BG every hour and adjust the dose of insulin to obtain an initial glucose goal of ___ mg/dL - then decrease infusion to ___ - ___ units/kg/hour and maintain glucose of ___ - ___ mg/dL until pt is menally alert - when mentally alert, transition to ___ insulin ( with 2-4 hour IV overlap)

- 0.1, 0.1 - 300 - 0.02-0.05 - 200-300 - SQ

# HHS Electrolytes - Sodium: monitor during fluid ___ - Phosphorus: only supplement if phos is < ___ mg/dL - Potassium: not as large as a problem in HHS (no ___ ). May supplement while on insulin drip or prn

- resuscitation - 1 - acidosis