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Therapeutics II > Diabetic Emergencies (DKA and HHS) > Flashcards

Diabetic Emergencies (DKA and HHS) Flashcards

1
Q

Diabetic Emergencies

A

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

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2
Q

Diabtic Ketoacidosis (DKA)

A

-hyperglycemia
-hyperketonemia
-metabolic acidosis

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3
Q

Hyperglycemic Hyperosmolar State (HHS)

A

-severe hyperglycemia
-hyperosmolality
-severe fluid depletion

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4
Q

Pathogenesis of Diabetic emergencies

A

-REDUCTION in circulating insulin efficacy
-ELEVATION of counter hormones

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5
Q

counterregulatory hormones

A

-glucagon
-catecholamines
-cortisol
-growth hormone

-counter insulin

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6
Q

Absolute insulin deficiency

A

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

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7
Q

Relative insulin deficiency

A

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

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8
Q

Diabetic Ketoacidosis background

A

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

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9
Q

Drugs that can lead to DKA

A

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

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10
Q

DKA patho

A

-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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11
Q

DKA clinical presentation

A

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

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12
Q

DKA classification

A

-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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13
Q

DKA diagnosis triad

A

-Hyperglycemia
-Hyperketonemia
-Metabolic acidosis

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14
Q

DKA goals of tx

A

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

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15
Q

Fluid management of DKA

A
  1. admin normal saline 500-1000mL/h for first 1-4 hours
  2. evaluate corrected Na at 2-4 houurs
  3. dec rate 50% change to 1/2 NS if corrected sodium normal or high, keep NS if low
  4. when BG 200mg/dL, change to D5W w 1/2NS at 150-300mL/h until resolution
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16
Q

Corrected sodium

A

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

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17
Q

Balanced Crystalloids

A

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

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18
Q

Insulin tx of DKA

A

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

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19
Q

IV insulin initiation

A

-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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20
Q

How does fluid help DKA

A

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

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21
Q

How does insulin help DKA

A

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

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22
Q

SQ insulin for DKA

A

-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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23
Q

When can you transition IV to SQ insulin

A

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

24
Q

Transitioning from IV to SQ insulin options

A

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

25
Q

Transitioning IV to SQ insulin in insulin-naive pt

A

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

26
Q

Getting off insulin IV

A

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

27
Q

72 kg insulin naive pt

A

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

28
Q

Labs to watch for DKA

A

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

29
Q

Anion gap

A

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

30
Q

Potassium

A

-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

31
Q

Potassium supplementation

A

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

32
Q

Sodium supplementation

A

-same as fluid admin
-consider balanced crystalloid

33
Q

Phosphate

A

-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)

34
Q

Bicarb supplementation

A

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

35
Q

Serum creatinine DKA

A

-should improve as fluids replaced

36
Q

White blood cell count in DKA

A

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

37
Q

Euglycemic DKA

A

-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

38
Q

DKA lab summary

A

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

39
Q

DKA tx summary

A

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

40
Q

DKA follow up

A

-endocrinology
-dietician
-social work
-med education

41
Q

PATIENT CASE!

A

PATIENT CASE!

42
Q

Hyperglycemic Hyperosmolar State (HHS) background

A

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

43
Q

HHS precipitating factors

A

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

44
Q

HHS patho

A

-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

45
Q

Clinical presentation of HHS

A

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

46
Q

HHS classification

A

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

47
Q

Calculating osmolality

A

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

48
Q

Goals of tx HHS

A

-restore volume
-restore urin output to 50mL/h or more
-return BG to normal

-fluids and insulin!

49
Q

Fluid tx HSS

A
  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
50
Q

Insulin tx HSS

A

-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)

51
Q

Electrolytes and HHS

A

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

52
Q

PT CASE!

A

PT CASE!

53
Q

DKA + HHS complications

A

-cerebral edema
-hypoglycemia

54
Q

cerebral edema

A

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

55
Q

Hypoglycemia

A

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

56
Q

DKA + HHS followup

A

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

57
Q

DKA + HHS charts

A

charts

Therapeutics II (55 decks)

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