Diabetic Emergencies!!!!!!!!!

Question 1

DKA requires immediate attention bc…

Answer 1

It’s a life threatening dz w/ 5% mortality in < 40 y.o. And 20% mortality in elderly

Question 2

DKA can be diagnosed with these 3 criteria:

Answer 2

1- hyperglycemia >250
2- ketosis: ketones in serum of blood
3- acidosis: pH <7.3 or serum bicarb <15

Question 3

Etiologies of DKA (7)

Answer 3

1- poor glucose control
2- pt. Newly dxed T1DM
3- infx: usually UTI or PNA
4- insulin pump failure or insulin leakage
5- SE of SLGT-2 usage
6- severe stress w/ T2DM: sepsis or trauma
7- setting w/ illness: MI, surgery, trauma, or pancreatitis

Question 4

Symptoms of DKA and onset:

Answer 4

Onset of s/s: 24-48 hrs

• -> can progress rapidly
• n/v/anorexia
• weakness and fatigue
• tachypnea (to blow of CO2)
• polydipsia/polyuria
• abdominal pain
• mental stupor–> coma

Question 5

Clinical signs of DKA:

Answer 5

• abdominal pain
• evidence of dehydration
• rapid deep breathing (kussmaul breathing)
• fruity breath odor
• worsening mental status changes
• hypotension/tachycardia

Question 6

DKA Lab findings: (8)

Answer 6

1- elevated blood glucose (250-600)
2- serum electrolytes: serum sodium-(serum bicarb+ serum Cl): shows AKI, mild hyponatremia, and low bicarb; anion gap elevated and >20
3- CBC w/diff: hemoconcentration (from dehydration) and leukocytosis (from stressor)
4- elevated plasma osmolality (increased salt)
5- UA and urine ketones: concentrated urine with high amounts of glucose and ketones
6- serum ketones: acetone, acetoacetic acid, & beta-hydroxybutyric acid (preferred)
7- ABG: likely not used if mild DKA; reveals degree of acidosis
8- ECG (stress on CV)

Question 7

What three factors contribute to the rapidity of DKA onset and severity?

Answer 7

1- hyperglycemia
2- ketoacidemia
3- fluid and electrolyte depletion

Question 8

Etiology behind hyperglycemia

Answer 8

• reduced or diminished insulin output–> so no glucose reuptake by cells
• IV starvation and glucagon predominates–> hepatic glycogenolysis leading to even higher glucose levels and FA breakdown–> ketone production and even more glucose in blood
  (Problem at the cellular level for glucose getting into cells)

Question 9

Etiology of ketoacidemia

Answer 9

Glucagon predominates and lipolysis and hepatic ketogenesis (starvation mode)

Question 10

etiology of fluid and electrolyte depletion

Answer 10

High ketones and blood glucose–> osmotic diuresis and excretion of fluid by kidney

Question 11

Average fluid loss in DKA

Answer 11

5 L

Question 12

Prevention of DKA:

Answer 12

• Most important to have pt. come in early
• patient education for early s/s
• ->+ for replenishing fluids and electrolytes
• at home ketone detection kit (of urine)
• additional insulin on sliding scale

Question 13

If persistent ketonuria exists x2 tests, patient should..

- List 2 worsening s/s:

Answer 13

Contact their MD!! Likely ED/hospitalization

+ vomiting; resistant to insulin increases

Question 14

Emergent Initial Tx of DKA includes..

Answer 14

1- thorough h&p (etiology)
2- pt. On tele and large IV NS wide open (Rq lots of fluid)
3- CBC, lytes, +/- cultures, ABG if critically ill; EKG and UA
4- serum K

Question 15

Begin insulin gtt only w/ serum K levels of:

Answer 15

> 5.3 mEq

Question 16

Begin both insulin gtt and K replacement w/ serum levels:

Answer 16

3.4-5.3 mEq/L

Question 17

Begin K replacement only w/ serum K levels of:

Answer 17

3.3 mEq/L or less

Question 18

Hospital tx of DKA involves:

Answer 18

1- insulin replacement
2- fluid replacement
3- K replacement

Question 19

Insulin replacement tx:

Answer 19

Initial bonus to prime insulin receptors–> IV insulin infusion drip
Initially 0.9% or 0.45% NS & convert to D5 with BG<250 (solution dependent on volume needs)

Question 20

Insulin replacement physiology:

Answer 20

1- corrects acidosis
2- reduces hyperosmolality
3- reduces hyperglucagonemia

Question 21

Fluid replacement specifics:

Answer 21

Most commonly w/ 4-5L
Hypovolemia ass. W/ adverse outcomes (at least 3-4L in 8 hr)
Hypervolemia–> ARDs and cerebral edema

Question 22

Potassium replacement tx:

Answer 22

• K loss w/ polyuria and vomiting
• Acidosis shifts k into extracellular space, so initial measurements higher on avg.
• correction of acidosis–> k shift intracellularly so replacement rq. In 2nd and 3rd hrs of tx (20-30 mEq/hr)

Question 23

C/I of potassium supplementation:

Answer 23

• anuria; persistent K>5; uremic (waste products in blood)

Question 24

other replacement metabolites in tx w/ DKA:

Answer 24

• phosphate (may be needed; replaced slowly)
• hypercholeremia: self-limiting in 12-24h
• sodium bicarb: controversial; only w/ severe acidosis (<7.0)

Question 25

Additional hospital management or considerations in DKA:

Answer 25

• NG tube: to decompress stomach
• strict I/O
• no narcotics/sedatives
• tx ass. Infx
• strict documentation and familial communication
• re-educate; check meds and discuss compliance; indicate severity of situation