Diabetic Emergencies Flashcards
Diabetic Emergencies - ___ states caused by severe insulin deficiencies (both ___ and ___ )
- diabetic ___
- hyperglycemic ___ state
- hyperglycemic
- endogenous
- exogenous
- ketoacidosis
- hyperosmolar
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 Background
Drugs that can cause DKA
- thiazides
- steroids
- sympathomimetics
- atypical antipsychostics
- SGLT-2 inhibitors
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
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: fluids
the case for balances crystalloids (LR, plasma-lyte, Normasol)
- might resolve DKA quicker
- less Cl (doesnt worsen acidosis)
- may also reduce AKI
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
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 < ___ 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
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
DKA: SQ Insulin - transitioninf from IV to SQ
Overlap IV and SubQ insulin by ___ hours to prevent rebound ketoacidosis or hyperglycemia
2-4
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
