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PHRM 844 > Diabetic Emergencies > Flashcards

Diabetic Emergencies Flashcards

1
Q

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

A
  • hyperglycemic
  • endogenous
  • exogenous
  • ketoacidosis
  • hyperosmolar
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2
Q

Diabetic Ketoacidosis (DKA)

  • Hyper___
  • Hyper___
  • metabolic ___
A
  • hyperglycemia
  • hyperketonemia
  • acidosis
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3
Q

hyperglycemic hyperosmolar state (HHS)

  • ___ hyperglycemia
  • hyper___
  • severe ___ depletion
A
  • severe
  • hyperosmolality
  • fluid

typically dont see ketoacidosis

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4
Q

DKA Background

  • usually occurs in type ___
  • leading precipitating factors: poor adherence and ___
A
  • T1DM
  • infection

leading cause of mortality in children with T1DM

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5
Q

DKA Background

Drugs that can cause DKA

A
  • thiazides
  • steroids
  • sympathomimetics
  • atypical antipsychostics
  • SGLT-2 inhibitors
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6
Q

DKA Symptoms

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

A

N/V, abdominal
- mental
- fruity
- Kussmaul

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7
Q

DKA Goals of Treatment

  • restore ___ volume ( ___ )
  • inhibit ___ and return of normal glucose metabolism ( ___ )
  • correct ___ imbalances ( supplement ___ )
A
  • circulatory, fluids
  • ketogenesis, insulin
  • electrolyte, electrolytes
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8
Q

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
A
  • 500-1000 mL/hr
  • Na
  • 1/2, 50%
  • 50%
  • 200 mg/dL, D5W, 150-250 mL/hr
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9
Q

DKA: fluids

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

A
  • might resolve DKA quicker
  • less Cl (doesnt worsen acidosis)
  • may also reduce AKI
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10
Q

DKA: insulin

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

A
  • IV
  • hourly
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11
Q

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)
A
  • 0.1, 0.1
  • hourly
  • 10%, 50-70 mg/dL
  • 0.1-0.14 units/kg
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12
Q

DKA: IV Insulin

  • fluids restore renal ___ , normal ___ , and volume status
  • excreting ___ and ___, restoring electrolyte balance
  • insulin is restoring normal ___ process (inhibiting ___ , stopping ___ , reducing ___ )
A
  • perfusion, osmolality
  • glucose, ketoacids
  • glycemic, glucagon, lipolysis, hyperosmolarity
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13
Q

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 ___

A
  • 200 mg/dL
  • 12
  • 15
  • 7.3
  • NPO
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14
Q

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 ___
A
  • SQ, 0.1
  • 0.5-0.8, 50/50
  • NPH
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15
Q

DKA: SQ Insulin - transitioninf from IV to SQ

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

A

2-4

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16
Q

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
A
  • positive, negative
  • 12
  • 12
  • SQ
17
Q

Anion Gap equation

A

= Na - (chloride + bicarb)

18
Q

HHS Background

  • ___ adults and type ___
  • underlying ___ or ___ disease
  • precipitaing factors may include heart attack, stroke, infection, recent procedure
  • inadequate __ intake
A
  • older, II
  • HF, kidney
  • fluid
19
Q

HHS Patho

  1. insulin deficiency or ___
  2. reduced utilization of glucose in ___ , muscle , and ___
  3. massive amounts of ___ in urine
  4. increased ___ loss / dehydration
  5. poor perfused ___
  6. decreased ability to clear excess ___ , leading to ___
  7. mental confusion, coma, seizures
A
  1. resistance
  2. liver, fat
  3. glucose
  4. water
  5. kidneys
  6. glucose, hyperosmolality
20
Q

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

A
  • growth hormone
  • insulin
21
Q

HHS Symptoms

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

severe:
- confusion
- coma
- seizures

A

weeks
- polyuria
- polydipsia

22
Q

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)

A

True

23
Q

DKA Patho

  1. non-adherence, infection, new diagnosis
  2. increased counterregulatory hormones (opposes circulating ___ )
  3. increased ___ glucose production, decreased peripheral insulin ___
  4. lack of peripheral glucose ___
  5. increased ___ in adipose tissue
  6. triglycerides break down into glycerol and ___
  7. FFAs break down into ___
A
  • insulin
  • hepatic, sensitivity
  • uptake
  • lipase
  • FFAs
  • ketones
24
Q

DKA Triad

  1. ___ glycemia
  2. ___ ketonemia
  3. metabolic ___
A
  • hyperglycemia
  • hyperketonemia
  • acidosis
25
Q

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
A
  • 0.02-0.05 units/kg/hr
  • 1/2 NS, D5W, 150-250 mL/hr
  • 150-200 mg/dL
26
Q

DKA: electrolytes and lab abnormalities

electrolytes of concern (4)
other pertinent labs (3)

A
  • K, Na, PO4, anion gap
  • pH, SCr, WBC
27
Q

DKA - Potassium

  • maintain K or ___ - ___ mmol/L
  • do NOT start insulin if K < ___ mmol/L

increased

A
  • 4-5
  • 3.3
28
Q

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

A
  • NS
  • 1/2 NS, 50%
  • NS, 50%
  • 200 mg/dL, D5W, 1/2NS
29
Q

T or F: phosphate is typically not replaced in DKA

A

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

30
Q

DKA - Bicarb

  • if pH is >/= 6.9 ….
  • if pH is < 6.9: give ___ - ___ mmol bicarb q1-2h until pH >/= 7
A
  • No bicarb
  • 50-100
31
Q

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
A
  • ketones
  • SGLT2
  • dextrose
32
Q

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
A
  • 800-2400
  • hyponatremia, hypernatremia
  • 100
  • 320
33
Q

HHS: goals of treatmment

  • restore circulatory volume via ___
  • restore urine output to __ mL/hr or more via
  • return BG to normal via ___ and ___
A
  • fluids
  • fluids
  • fluids, insulin
34
Q

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
A
  • 1/2 NS, NS
  • Na
  • rate
  • NS
  • 300
  • D5W, 1/2 NS
35
Q

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)
A
  • 0.1, 0.1
  • 300
  • 0.02-0.05
  • 200-300
  • SQ
36
Q

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
A
  • resuscitation
  • 1
  • acidosis

PHRM 844 (52 decks)

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