Diabetic Emergencies (DKA and HHS) Flashcards by Brooke Thornburg

Diabetic Emergencies

-hyperglycemic states
-leading cause of death in T1DM kids
-Diabetic Ketoacidosis (DKA)
-Hyperglycemic Hyperosmolar state (HHS)

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Diabtic Ketoacidosis (DKA)

-hyperglycemia
-hyperketonemia
-metabolic acidosis

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Hyperglycemic Hyperosmolar State (HHS)

-severe hyperglycemia
-hyperosmolality
-severe fluid depletion

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Pathogenesis of Diabetic emergencies

-REDUCTION in circulating insulin efficacy
-ELEVATION of counter hormones

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counterregulatory hormones

-glucagon
-catecholamines
-cortisol
-growth hormone

-counter insulin

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Absolute insulin deficiency

-lipolysis
-FFA to liver (can also inc gluconeogenesis = hyperglycemia)
-ketogenesis and acidosis
-TGs and hyperlipidemia
=DKA

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Relative insulin deficiency

-absent or minimal ketogenesis
-glycogenolysis
-hyperglycemia
-dehydration = hyperosmolarity
=HHS

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Diabetic Ketoacidosis background

-usually T1DM sometimes new T2DM
-poor adherence to tx
-infection or illness
-meds

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Drugs that can lead to DKA

-Thiazides
-Steroids
-Sympathomimetics
-Atypical antipsychotics
-SGLT2 inhibitors

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DKA patho

-precipitating factors
-inc counter hormones
-inc hepatic glucose production / dec insulin sensitivity
-lack glucose uptake
-inc lipase in adipose
-TGs to FFAs to ketones

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DKA clinical presentation

-poly symptoms (in hunger and thirst)
-N/V
-ab pain
-changes in mental status
-fruity (acetone) breath
-coma

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DKA classification

-all >250 BG
-pH gets lower with severity
-serum bicarb dec w severity
-positive ketones
-anion gap inc w severity >10

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DKA diagnosis triad

-Hyperglycemia
-Hyperketonemia
-Metabolic acidosis

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DKA goals of tx

-restore circulatory volume (Fluids)
-inhibit ketogenesis and return of normal glucose metabolism (insulin)
-correct electrolytes (supplements)

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Fluid management of DKA

admin normal saline 500-1000mL/h for first 1-4 hours
evaluate corrected Na at 2-4 houurs
dec rate 50% change to 1/2 NS if corrected sodium normal or high, keep NS if low
when BG 200mg/dL, change to D5W w 1/2NS at 150-300mL/h until resolution

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Corrected sodium

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

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Balanced Crystalloids

-LR, plasma-lyte, normasol
-might be better than NS bc Cl can deplete bicarb making acidosis worse

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Insulin tx of DKA

-second step of tx after fluids start
-admin IV, SQ, IM (IV preffered)
-hourly labs and BG checks

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IV insulin initiation

-regular insulin
-0.1 units/kg/h +/- bolus of 0.1 units/kg
-repeat or inc dose (0.1-0.14 units/kg) if glucose does not fall by 10% or more in first hour (50-70mg/dL)
-when glucose 200, dec infusion rate to 0.02-0.05units/kg/h! AND change NS to NS+D5W and dec rate to 150-250mL/h

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How does fluid help DKA

-fluids restore renal perfusion, osmolality, and volume status
-excreting glucose and ketoacids = restore elecetrolyte balance

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How does insulin help DKA

-restore normal glycemic processes
-inhibit glucagon (stop gluconeogenesis)
-stop lipolysis (FFA production)
-reduce hyperosmolarity by correcting hyperglycemia

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SQ insulin for DKA

-0.2 units/kg every 2 hours +/- bolus 0.2unit/kg
-check BG q2h and adjust dose to maintain glucose of 150-200mg

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When can you transition IV to SQ insulin

-BG < 200
-and 2+ of the following:
-anion gap closes < 12
-bicarb > 15
-pH > 7.3
-pt should not be NPO ideally

Transitioning from IV to SQ insulin options

opt 1. restart home regimen if that worked
opt 2. consider SQ rapid acting insulin q2h at 0.1 units/kg adjusted PRN
opt 3. if insulin-naive, start basal/bolus regimen TDD 0.5-0.8 units/kg/day divided 50/50 between basal-bolus
opt 4: add total amt of IV insulin required by pt and convert to estimated daily requiredment using basal/bolus or q6h NPH insulin

Transitioning IV to SQ insulin in insulin-naive pt

-start basal/bolus -TDD 0.5-0.8 units/kg/day divided 50/50 between basal and bolus

Getting off insulin IV

-overlap IV and SQ by 2-4h! to prevent rebound DKA and hyperglycemia

72 kg insulin naive pt

-summarize insulin needs over 6 hours =10 units q6h -estimate daily need 10*4= 40 units - or 10 units NPH q6h SQ

Labs to watch for DKA

-potassium -sodium -phosphate -anion gap -pH -Serum creatinine -WBC

Anion gap

-positive charges minus negative charges -Na - (Cl+Bicarb) ->12 is acidosis -when gap closes <12, can consider transitioning IV to SQ

Potassium

-normal 3.5-5.5 -about 5 in acidosis -maintain 4-5 mmol/L w fluids -DO NOT START INSULIN IF K <3.3 mmol

Potassium supplementation

-K>5: none -4-5: 20mEq/L to fluids -3-4: 40mEq -<3: 10-20mEq/HOUR til over 3 then supplement w 40

Sodium supplementation

-same as fluid admin -consider balanced crystalloid

Phosphate

-dec w insulin therapy -not much benefit in replacing it -may supp as potassium phosphate in fluids in pts presenting w phosphate < 1mg/dL and comorbidites (anemia, CV, respiratory depression)

Bicarb supplementation

-pH < 6.9 -give 50-100mmol q1-2h until pH > 7

Serum creatinine DKA

-should improve as fluids replaced

White blood cell count in DKA

-normal or elevated (10-15000) due to stress/cortisol -dont need abx unless showing ss of infection -WBC > 25000 might be infection

Euglycemic DKA

-pt presents w normal or slightly elevated BG (~200) -urine still positive for ketones -might be caused by poor oral intake, pregnancy or SGLT2 INHIBITORS! -might require dextrose earlier in therapy but tx generally similar

DKA lab summary

-pH < 7.3 -low bicarb -ketones -inc K -low Na -elevated BG

DKA tx summary

-NS or LR + IV insulin drip + electrolyte replacement -add D5 to IV -transition to SQ -monitor electrolytes

DKA follow up

-endocrinology -dietician -social work -med education

PATIENT CASE!

Hyperglycemic Hyperosmolar State (HHS) background

-older adults -rarer than DKA -pt usually have underlying HF or kidney disease

HHS precipitating factors

-heart attack -stroke -infection -recent procedure -phenytoin -corticosteroids -diuretics

HHS patho

-insulin resistance -dec utilization of glucose -inc hepatic glucose -glucosuria -inc water loss = dehydration -dec ability to clear excess blood glucose -hyperosmolality = confusion, coma, seizure

Clinical presentation of HHS

-weakness -hunger/thirst -severe: confusion, coma, seizure

HHS classification

-glucose 800-2400 -mild = low Na -severe = high Na -absent or mild ketosis -BUN >100 -pH ~ 7.3 -osmolality >320

Calculating osmolality

(Na*2) + (BUN/2.8) + (glucose/18)

Goals of tx HHS

-restore volume -restore urin output to 50mL/h or more -return BG to normal -fluids and insulin!

Fluid tx HSS

1. admin 1/2 NS!! of 500-1000mL/h for first 1-4 hours 2. evaluate corrected sodium 3. reduce rate if normal or high, consider NS if low 4. when BG 300!, change to D5w w 1/2 NS at 150-250mL/h til resolved

Insulin tx HSS

-0.1 units/kg/h +/- bolus of 0.1 units/kg -check BG q1h and adjust to obtain 300mg -then dec infusion to 0.02-0.05 units/kg/h and maintain BG 200-300 until pt mentally alert -transition to SQ when mentally alert (2-4 hours overlap)

Electrolytes and HHS

-monitor sodium w fluids -only supp phos if < 1mg -potassium sup while on insulin drip or as needed but not as bad as DKA

PT CASE!

DKA + HHS complications

-cerebral edema -hypoglycemia

cerebral edema

-maybe bc osmolality reduced too fast -HA, fatigue -can lead to seizures, bradycardia, resp arrest -tx w mannitol + ventilation -dont hydrate too fast

Hypoglycemia

-caused by too much insulin -tx: reduce insulin rate, give glucose, consider glucagon

DKA + HHS followup

-ensure pt has follow up -assess ability to pay for meds -educate on discharge diabetes regimen -prevent readmission

DKA + HHS charts

charts