DKA and HHS

Question 1

What do we generate fuel-wise in a prolonged fasting state?

Answer 1

1. Ketones made for energy to CONSERVE protein

2. Ketonemia can lead to METABOLIC ACIDOSIS!!

Question 2

Pathophys of DKA and HHS:

Answer 2

1. Absolute or relative insulin deficiency
2. Increase in counter-reg hormones: stress, infection, meds
3. Volume depletion (5-12 L)

Question 3

Insulin deficiency:

Answer 3

1. Think type 1 diabetes or ketosis-prone type 2 diabetes
2. Noncompliance with insulin
3. Expired insulin
4. Insulin pump failure

Question 4

Four counter-reg hormones:

Answer 4

1. Glucagon
2. Cortisol
3. Growth hormone
4. Epinephrine;
   think gycogenolysis and gluconeogenesis

Question 5

Precipitating factors of DKA and HHS:

Answer 5

1. Think INFECTION
2. Insulin (new-onset diabetes)
3. Infarct!!

Question 6

How can one become volume depleted in DKA or HHS?

Answer 6

1. Hyperglycemia (low insulin and elevated counter-reg hormone levels)
2. Exceed glucose reabsorption (160-190) and you have osmotic diuresis from glucosuria and electrolyte losses (Na and K)
3. Severe water loss (polyuria, dehydration, increased thirst, polydipsia, and then tissue hypoperfusion leading to lactic acidosis)

Question 7

Path of DKA:

Answer 7

1. Decreased effective insulin concentration and increase in counter-reg hormones (ketosis and hyperglycemia; have lipolysis of adipose tissue and increased FFA’s; also unrestrained hepatic FA oxidation to ketone bodies)
2. Hyperglycemia: increased gluconeogensis, increased glycogenolysis, impaired glucose utilization by peripheral tissues
3. Transient insulin resistance: hormone imbalance (counter-reg hormones) and elevated FFA concentrations

Question 8

Path of HHS:

Answer 8

1. Relative insulin deficiency leads to hyperglycemia leading to osmotic diuresis and then dehydration;
   however enough insulin to prevent lipolysis and ketogenesis, and not enough insulin to allow for glucose utilization

Question 9

Clinical presentation of DKA vs. HHS:

Answer 9

1. DKA: type 1 DM, generally young, abdo discomfort, vomiting and Kussmaul respirations; vascular shock and mental status changes;
2. HHS: type 2 DM, generally elderly, debilitating disease, volume contraction; generally WITHOUT ketoacidosis, mental status changes

Question 10

DKA diagnostic criteria vs. HHS criteria:

Answer 10

1. Hyperglycemia
2. Metabolic acidosis
3. Ketone production;
4. Hyperglycemia
5. Hyperosmolality
6. Dehydration

Question 11

Sick Day rules:

Answer 11

1. Take insulin even when NOT eating
2. Increase freq of testing and titrate insulin appropriately
3. Drink fluids
4. Monitor urine KETONES
5. Worry about high glucose or vomiting

Question 12

Fluids doled out as:

Answer 12

1. IV NS 1-2 L or until patient not orthostatic
2. IV NS or .5 NS depending on corrected serum Na, hemodynamics, and urine output (DON’T correct hyperosmolality too quickly, and calculate the body water deficit)
3. Give IV .5 NS with D5W once glucose levels are 200 mg/dL

Question 13

For insulin, when is this indicated?

Answer 13

Continuous regular insulin infusion preferred;

1. Have glucose fall 50-75 mg/dL/hr (adjust insulin infusion)
2. As glucose gets to 200-300, add fluids to maintain glucose concentrations until DKA resolves
3. Hyperglycemia corrects faster than ketoacidosis
4. MUST overlap insulin infusion with subq insulin by 1-2 hrs to prevent hyperglycemia/ketoacidosis recurrence

Question 14

For K, what should we do?

Answer 14

1. It enters cells with treatment of insulinopenia and acidemia
2. Monitor: height of T wave directly proportional with K level
3. AVOID HYPOKALEMIA (risk of ventricular arrhythmias)

Question 15

What are we worried about with bicarb?

Answer 15

1. Exacerbates hypokalemia, decreases tissue O2 uptake, cerebral edema, paradoxical CNS acidosis;
2. Give ONLY in severe acidosis (pH less than 6.9) or severe hyperkalemia (K greater than 6.5 or EKG changes)

Question 16

Labs to look out for in DKA or HHS:

Answer 16

1. Na (use corrected Na to calculate water deficit)
2. Leukocytosis: can be as high as 25000 b/c of stress but infection also
3. Serum osmolality 281-297

Question 17

Facts about ketones:

Answer 17

1. Present under normal circumstances (starvation, alcohol, pregnancy)
2. Acetoacetic acid:beta-HBA usually 1:1 up to 1:3
3. In DKA, can go up to 1:10 as redox state changes (beta-HBA predominate ketone in DKA)

Question 18

Ames Acid test measures _____ in blood and urine; does not test _____; what is the normal ketone range and what is it in DKA? What is the problem following ketones here?

Answer 18

acetoacetic acid; beta-HBA;
less than .15 mmol/L, and 3-30 mmol/L in DKA;
ketones decrease more slowly than glucose, and worried about paradoxical ketonuria with redox potential changes as more beta-HBA converted into acetoacetate

Question 19

Cutoff for DKA is; we should follow

Answer 19

2 (beta-HBA usually .02-.27 mmol/L);

anion gap and glucose

Question 20

Resolving DKA and HHS, and possible complications:

Answer 20

1. DKA with glucose less than 200, and two of bicarb over 15, venous pH over 7.3, and calculated anion gap less than 12;
2. HHS with normal osmolality and mental status;
   Complications:
3. hypoglycemia (start dextrose with glucose less than 200)
4. Hypokalemia (monitor)
5. Hyperchloremic non-anion gap metabolic acidosis (recovery phase of DKA, but it’s self-limiting)
6. Cerebral edema (rapid fluid correction, excessive bicarb, hyponatremia, glucose falls below 200): treat with 1-2 g mannitol, dexamethasone, and intubation with hyperventilation but not effective, so avoid onset and DKA

Question 21

Acid base:

Answer 21

1. What is the osis? Over 7.45 or less than 7.35
2. Look at bicarb (metabolic or respiratory)
3. Is there compensation?
4. If metabolic acidosis: determine anion gap (if elevated, check Winter’s formula and delta-delta, then check ketones, and with ketones negative check other stuff)
5. For delta-delta, if delta bicarb greater than delta AG then you have concomitant non-AG acidosis, and if vice versa, you have concomitant metabolic alkalosis alongside AG acidosis

Question 22

What could precipitate DKA?

Answer 22

Infection, other physical stress, discontinued insulin, ineffective insulin, etc.

Question 23

If treating DKA, best lab value to follow? What electrolytes need to be followed?

Answer 23

Follow AG!! Can’t follow glucose since it will resolve prior to ketone resolution, and don’t follow ketones unless beta-HBA measured directly;
Na, K, bicarb, Cl;
also follow AG!!!

Question 24

In HHS, what can cause altered mental status?

Answer 24

1. Hyperosmolar state (hyperglycemia and dehydration)
2. Acute renal failure
3. Hypercalcemia

Question 25

For HHS, what can cause decompensation?

Answer 25

1. Infection
2. Counterreg hormone increase
3. Insulin resistance
4. Hyperglycemia
5. Dehydration