DKA and HHS

Question 1

Precipitating factors

Answer 1

infection, MI, medications, poor “sick day” management, pancreatitis, drug/alcohol abuse, stress, inadequate dose of insulin

Question 2

DKA vs HHS onset

Answer 2

DKA: hours to day
HHS: days to weeks

Question 3

DKA vs. HHS clinical picture

Answer 3

Both: polyuria, polydipsia, dehydration, weight loss
DKA: N/V, abd pain, Kussmaul respirations
HHS: neurologic manifestations (seizures), changes in mental

Question 4

DKA vs HHS labs

Answer 4

DKA: glucose >250, acidosis <7.3, anion gap >12, ketones +, serum osmol <320
HHS: glucose >600, no acidosis, anion gap variable, ketones -, serum osmol >320

Question 5

euglycemic DKA

Answer 5

BG <200 mg/dL

Question 6

risk factors for euglycemic DKA

Answer 6

pregnancy, SGLT2i use**, reduced food intake, alcohol use, liver failure

Question 7

obtain serum ketones if presenting with SGLT2i and:

Answer 7

-low carb diet
-dehydration
-prolonged fasting
-excessive alcohol intake

Question 8

DKA diagnosis

Answer 8

D: Diabetes/hyperglycemia
K: Ketosis
A: metabolic Acidosis

Question 9

HHS diagnosis

Answer 9

H: Hyperglycemia
H: Hyperosmolarity
S: abSense of ketones and acidosis

Question 10

mild DKA

Answer 10

-pH: 7.25-7.3
-bicarb: 15-18 mmol/L
-mental: alert
-LOC: regular or obs

Question 11

moderate DKA

Answer 11

-pH: 7.0-7.25
-bicarb: 10-15 mmol/dL
-mental: alert/drowsy
-LOC: sdu or icu

Question 12

severe DKA

Answer 12

-pH: <7.0
-bicarb: <10 mmol/dL
-mental: coma
-LOC: icu

Question 13

IV fluids treatment

Answer 13

-severe hypovolemia → NS or other crytalloid (1L/hr)
-mild hypovolemia → NS or other crystalloid to replace 50% of fluid deficit in 8-12h
-cardiac compromise → hemodynamic monitoring/pressors

Question 14

mild DKA insulin treatment

Answer 14

sq insulin
-0.1 u/kg rapid acting bolus
-0.1 u/kg q1h or 0.2 u/kg q2h of rapid acting
-glucose <250 → reduce to 0.05 u/kg/hr iv
-keep glucose between 150-200 mg/dL until resolution

Question 15

mod-sev DKA insulin treatment

Answer 15

iv insulin
-0.1 u/kg short acting bolus
-0.1 u/kg/h short acting drip
-glucose <250 → reduce to 0.05 u/kg/hr iv
-keep glucose between 150-200 mg/dL until resolution

Question 16

HHS insulin treatment

Answer 16

iv insulin
-0.05 u/kg/h short acting drip
-target glucose between 200-250 mg/dL

Question 17

potassium treatment if K <3.5 mmol/L

Answer 17

10-20 mmol/L/h until K >3.5 mmol/L

Question 18

potassium treatment if K 3.5-5.0 mmol/L

Answer 18

10-20 mmol/L in each liter of fluid as needed to keep serum K between 4-5 mmol/L

Question 19

potassium treatment if K >5.0 mmol/L

Answer 19

start insulin but do not give K. check K every 2 hours

Question 20

fluid management treatment pearl

Answer 20

5% or 10% dextrose should be added to balanced crystalloids once BG reaches 250 mg/dL or at start of insulin treatment in euglycemic DKA

Question 21

monitoring

Answer 21

check electrolytes, renal function, pH, osmolality, and BG every 2-4 hrs until stable

Question 22

goals of treatment for DKA

Answer 22

-BG: 150-200 mg/dL
-pH: >7.3
bicarb: >18 mmol/L

Question 23

goals of treatment for HHS

Answer 23

-BG: 200-250 mg/dL
-serum osmol: <300

Question 24

weight based conversion from iv to sq insulin

Answer 24

-0.5-0.6 u/kg/d TDD
-0.3 u/kg/d for those with high risk for hypoglycemia (frail, ckd)

Question 25

pre-admission insulin requirements for conversion from iv to sq

Answer 25

-consider TDD of insulin regimen outpatient

Question 26

hourly IV insulin conversion for iv to sq

Answer 26

-summation of stable hourly iv insulin

Question 27

iv to sq general principles

Answer 27

-start sq insunlin 1-2h prior to d/c of iv -ensure regimen provides 24h coverage

Question 28

TOC and discharge non-insulin agents

Answer 28

don't initiate or continue SGLT2i during hospitalization

Question 29

TOC and discharge plans

Answer 29

-basal/bolus is recommended, 24h coverage -d/c plans should include follow-up for review

Question 30

when is giving bicarb recommended

Answer 30

pH <7.0 -100 mmol in 400 mL of SWFI over 2 hours -repeat q2h until pH >/7

Question 31

phosphate treatment indication

Answer 31

cardiac dysfunction, respiratory depression, serum phos <1.0 mg/dL

Question 32

complications of hyperglycemic crisis

Answer 32

hypoglycemia, hypokalemia, hyperchloremic non-anion gap metabolic acidosis, cerebral edema, thrombosis, AKI