Diabetic Emergencies Flashcards by Corey Brend

What can cause diabetic ketoacidosis?

-Hyperglycemia
-Hyperketonemia
-Metabolic acidosis

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What can cause hyperglycemic hyperosmolar state?

-Severe hyperglycemia
-Hyperosmolality
-Severe fluid depletion

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What is the pathophysiology surrounding DKA and HHS?

The basic underlying mechanism for both disorders is a reduction in the net effective action of circulating insulin coupled with concomitant elevation of counterregulatory hormones, such as glucagon, catecholamines, cortisol, and growth hormone

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What type of diabetes typically experiences DKA?

It usually occurs in T1DM or new-onset T2DM

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What are the leading precipitating factors of DKA?

-Poor adherence to treatment regimen
-Infections

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Which drugs can cause DKA?

-Thiazides
-Steroids
-Sympathomimetics
-Atypical antipsychotics
-SGLT2 inihibitors

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Symptoms of DKA

-Polyuria, polydipsia, weight loss, dehydration
-Nausea/vomiting (40-75% of patients)
-Abdominal pain (40-75% of patients)
-Changes in mental status
-Fruity breath
-Kussmaul respirations
-Coma

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Glucose level in mild DKA

Over 250

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Blood pH in mild DKA

7.25-7.3

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Bicarbonate level in mild DKA

15-18

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Anion gap in mild DKA

Over 10

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Glucose level in moderate DKA

Over 250

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Blood pH in moderate DKA

7-7.24

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Bicarbonate level in moderate DKA

10-14

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Anion gap in moderate DKA

Over 12

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Glucose level in severe DKA

Over 250

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Blood pH in severe DKA

Less than 7

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Bicarbonate level in severe DKA

Less than 10

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Anion gap in severe DKA

Over 12

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DKA triad

-Hyperglycemia
-Hyperketonemia
-Metabolic acidosis

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Goals of treatment for DKA

-Restore circulatory volume (Fluids)
-Inhibit ketogenesis and return to normal glucose metabolism (insulin)
-Correct electrolyte imbalances (supplement electrolytes)

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How to restore circulatory volume in DKA

-Administer 0.9% sodium chloride at 500-1000 mL/hr for first 1-4 hours
-Evaluate corrected Na at 2-4 hours
- If corrected Na is normal/high: change to 1/2 NS and decrease the rate by 50%
-If corrected NA is low: continue NS and decrease the rate by 50%
-When blood glucose approaches 200mg/dL, change to D5W w/ 1/2 NS @150-250 mL/hr until resolution of ketoacidosis

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How do you find corrected sodium?

measured sodium + 1.6[(glucose - 100)/100]

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When do you initiate insulin therapy in patients with DKA?

Insulin therapy is the second step in the management of DKA after fluids are initiated

What is the preferred way to administer insulin for patients with DKA?

IV continuous infusion is preferred but can also be SubQ or IM

How do you dose insulin for patients with DKA?

-Start 0.1 units/kg/hour +/- a bolus of 0.1 units/kg -Check glucose every hour -If glucose does not fall by 10% or more in first hour, give, repeat, or increase bolus dose (0.1-0.14 units/kg)

When do you transition to SubQ insulin from IV in patients with DKA?

-When the blood glucose level is less than 200 -Meets at least 2 of the following criteria -Anion gap closes at 12 mEq/L or less -Bicarbonate level is 15 mEq/L or more -Venous pH is greater than 7.3 Ideally the patient should be able to eat

How do you dose SubQ insulin for patients with DKA and HHS?

-You can restart home regimen if it was working previously -Consider SubQ rapid-acting insulin every 2 hours at 0.1 units/kg adjusted as needed to maintain goal -If the patient is insulin-Naive, start multidose regimen of 0.5-0.8 units/kg/day, divided 50/50 basal/bolus -Consider adding up the total amount of IV insulin required by patient and convert to estimated daily requirement using basal/bolus or every 6 hour NPH

What should you always do when switching from IV insulin to SQ insulin to prevent rebound ketoacidosis or hyperglycemia?

Overlap IV and SQ insulin by 2-4 hours

What are the electrolytes of concern when it comes to DKA?

-Potassium -Sodium -Phosphate -Anion gap

What are some pertinent lab values to consider when treating someone with DKA?

-pH -SCr -WBC

How do you calculate anion gap?

Na - (chloride + bicarbonate)

What anion gap suggests metabolic acidosis?

A gap of greater than 12 mEq/L

At what anion gap level can you consider transitioning from IV insulin to SQ insulin?

At a gap of less that 12

What K level do you want to maintain in DKA?

Maintain a K of 4-5 mmol/L

What K level can you not start insulin?

Do not start insulin if K is less than 3.3mmol/L

What should you do when a DKA patient has a K level greater than 5?

No supplementation

What should you do when a DKA patient has a K level between 4-5?

Add 20 mEq KCl per liter to replacement fluids

What should you do when a DKA patient has a K level between 3-4?

Add 40 mEq KCl per liter to replacement fluids

What should you do when a DKA patient has a K level below 3?

Add 10-20 mEq/hour until K is greater than 3, then supplement 40 mEq

How do you treat DKA patients with abnormal phosphate levels?

-Phosphate concentration decreases with insulin therapy, but no studies have suggested benefit in replacing phosphate acutely -May be supplemented as potassium phosphate in fluids in patients presenting with a phosphate level lower than 1 and comorbidities such as anemia, cardiac dysfunction, or respiratory depression

At what pH is bicarb supplementation recommended?

Less than 6.9

How do you supplement bicarb in DKA patients?

Give 50-100 mmol bicarb every 1-2 hours until pH is 7 or greater

How should serum creatinine abnormalities be treated in DKA patients?

Should improve as fluids replaced

How should increased white blood cell count be treated in DKA patients?

Likely do not need antibiotics unless showing other signs or symptoms of infection

At what WBC level is it more indicative of an infection?

WBC greater than 25,000

Precipitating factors of HHS

Heart attack, stroke, infection, recent procedure

What kind of patients does HHS typically occur in?

-Older adults -Many patients have underlying heart failure or kidney disease

Symptoms of HHS

-Polyuria -Polydipsia -Dehydration w/ reduced fluid intake -Lethargy -Confusion -Coma -Seizures

Typical glucose level in HHS patients

~800-2400

Typical BUN in HHS patients

Often severely elevated > 100mg/dL

Typical serum osmolality in HHS patients

over 320

How do you calculate osmolality in HHS patients?

(Nax2) + (BUN/2.8) + (glucose/18)

Goals of treatment for HHS

-Restore circulatory volume (fluids) -Restore urine output to 50 mL/hour or more (fluids) -Return blood glucose to normal (fluids + insulin)

Fluid treatment for HHS

-Administer 1/2 NS or NS at 500-1000 mL/hr for first 1-4 hours -Evaluate corrected Na at 2-4 hours -If corrected Na normal/high: reduce the rate -If corrected Na low: consider NS -When blood sugar is 300 mg/dL, change to D5W w/ 1/2 NS @ 150-250 mL/hr until resolution of HHS

Goal blood sugar for DKA

200

Goal blood sugar for HHS

300

Insulin treatment for HHS

-Start 0.1 units/kg/hour +/- a bolus of 0.1 units/kg -Check glucose every hour and adjust dose of insulin to obtain an initial glucose goal of 300 -Then decrease infusion to 0.02-0.05 units/kg/hour and maintain glucose of 200-300 mg/dL until patient is mentally alert -Once mentally alert, transition to SQ insulin (with overlap)