DKA and HHS

Question 1

DKA and HHS

how serious are they?

Answer 1

DKA and HHS are the two most serious acute metabolic complications of diabetes

Question 2

Precipitating Factors

Answer 2

Precipitating Factors

1. infections(UTI and pneumonia)
2. MI stress
3. Medications
4. poor sick day manegement
5. inadequate doe or d/c of insulin
6. pancreatitis
7. drug/alcohol abuse

Question 3

main categories of pharmacologic treatment of DKA and HHS

Answer 3

fluid management
insulin therapy
potassium treatment
SErum bicarbonate

Question 4

Fluid management

Answer 4

Fluid management

initial: NS 15-20 ml/kg for the first hour

subsequent treatment:

a. moderate-severe hypovolemia. greater volumes needed
b. cariogenic shock: utilize pressers and monitor hemodynamics closely.

Once BG=200 mg/dL for DKA or 300 for HHS, change to 0.45% NS NaCl/ D5W at 150-250 mL/hr

Question 5

Insulin Therapy

Answer 5

Insulin Therapy

1. IV insulin (Regular) has short half life

Dosing:
0.1 unit/kg as an IV bolus, then 0.1 kg/hr continuous infusion
OR
0.14 unit/kg/hr as an IV continuous infusion only (no bolus)

low dose insulin infusions should lower BG concentrations by 50-75% mg/dL/h
a. if BG not decreased in first hour , recommend to increase infusion qh until steady decline blood glucose achieved

Once BG=200 mg/dL for DKA or 300 for HHS, decrease to 0.02-0.05 units/kg/hr IV until goals are met

Goal BG in Treatment

DKA:150-200 mg/dL until resolution

HHS: 200-300 mg/dL until patient is mentally alert

Question 6

Potassium Treatment

Answer 6

Potassium Treatment

Treatment of DKA and HHS with insulin and fluids pushes potassium into cells, increasing risk for kypokalemia. Needing forL+ supplementation

1. Check K+ before initiating insulin therapy

if K+<3.3 mEq/L: hold insulin and replete @ 20-30 mEq/hr until the k+ 3.3 mEq/L

if k+ 3.3-5.5 mEq/L: 20-30 mEq k+ should be given with every L of fluid

if k+ >5.: do not give K+ until it falls below UNL. monitor q2hr

Question 7

Transition from IV to SQ

Answer 7

Transition from IV to SQ

1. Resolution of crisis and patient able to eat, initiate SQ basal insulin and overlap with IV infusion for 1-2 hours (to give sq insulin time to work)

if pt has hx of DM with insulin:
a.can use dose prior to admission9but in practice-usually reduce dose)

insulin naive:
multi dose regimen with basal (glargine and deter)+bolus (lisper, aspart, or glulisine) started at a dose of 0.5-0.8 units/kg/day

Question 8

Serum Bicarbonate Treatment

Answer 8

Serum Bicarbonate Treatment

only indicated in patients with a pH < 6.9

give 100 mmol (2 ampules) in 400 mL of H2O +20 mEqof KCl over 2 hours. repeat q2h until the pH >/=

risk associated with sodium bicarbonate use:
a.increased hypokalemia risk
b.decrease in tissue O2 uptake
cerbral edema
paradoxical CNS acidosis

Question 9

Resolution in treatment

how do you know the dka/ hhs is resolved?

Answer 9

Resolution in treatment

DKA: BG<200 AND 2 of following

a. serum bicarbonate level >/= 15 mEq/L
b. venous pH > 7.3
c. anion gap = 12 mEq/L

HHS: normal osmolality AND normal mental status