DKA and HHS

Question 1

what does insulin do in the fed state?

Answer 1

as always it is the anabolic hormone so it causes uptake of glucose into cells, thus decreasing glucose concentration in the blood. translocation of the GLUT4 receptor. stimulates storage of glucose in the lover as glycogen. promotes synthesis of ffatty acid stimulates the uptake of amino acids. increases permeability of potassium, phosphate and magnesium

Question 2

which tissues do not depend on GLUT4?

Answer 2

brain and liver

Question 3

what happens to insulin secretion as the glucose concentration declines?

Answer 3

it decreases. cells become unable to take up glucose and rely on alternative metabolisms

Question 4

what does glucagon do?

Answer 4

increases the breakdown of glycogen. lipolysis, gluconeogenesis also occur

Question 5

what is the role of ketones?

Answer 5

they are used in prolonged fasting to preserve the body muscle.

Question 6

what is the pathophysiology of DKA and HHSq

Answer 6

relative insulin deficiency. increase in the amount of counter regulatory hormones (due to infection, stress, medication) volume depletion (5-12 liters).

Question 7

what are the counter regulatory hormones>

Answer 7

glucagon, cortisol, epinephrine, growth hormone.

Question 8

what is the pathogenesis of DKA?

Answer 8

decreased relative insulin causes increased glucagon/regulatory hormones. this causes reliance on alternative metabolism: lipolysis, ketosis and hyperglycemia (lack of use, lack of insulin to push it into cells, etc). formation of ketones to keep tissues happy, excessive diuresis due to glucose leads to dehydration and thirst.

Question 9

HHS pathogenesis

Answer 9

relative decrease in insulin leads to hyperglycemia, osmotic diuresis and dehydration. however there is enough insulin to keep lipolysis and ketogenesis away, but not enough to increase glucose utilization.

Question 10

DKA presentation

Answer 10

T1DM, generally young, abdominal discomfort, vomiting, kussmaul respirations, vascular shock, mental status changes.

Question 11

HHS presentation

Answer 11

T2DM, generally elderly, debilitating disease, volume contraction, without ketosis. mental status changes.

Question 12

how many patients have overlap between ketosis and HHS

Answer 12

1/3

Question 13

what is the triad of DKA

Answer 13

hyperglycemia, metabolic acidosis, ketone production.

Question 14

what is the triad of HHS

Answer 14

hyperglycemia, hyperosmolarity, dehydration. there is absence of significant ketosis.

Question 15

best treatment plan for HHS/DKA

Answer 15

take insulin even when not eating, increase the frequency of testing and titrate insulin, drink fluids, monitor urine ketone. if continuously high glucose or vomit call MD.

Question 16

what is meticulous treatment? 14 things

Answer 16

fluids, insulin, potassium, bicarbonate, sodium, ketones, acidbase, phosphate, creatinine, lactic acid, leukocytosis, amylase, liver function, hypertriglyceridemia.

Question 17

when to give bicarbonate?

Answer 17

impaired myocardial function, cerebral vasodilation, pulmonary vasoconstriction, coma, GI compilcations. ONLY IN SEVERE acidosis (pH 6.5

Question 18

why not give bicarb?

Answer 18

too much causes hypokalemia, decreased tissue oxygenation, cerebral edema, paradoxical CNS acidosis.

Question 19

what lab to follow to see if treatment is working?

Answer 19

do not follow ketones because they move slower than glucose. follow anion gap and the glucose.

Question 20

what are some complications of HHS/DKA

Answer 20

hypoglycemia (may need to start dextrose), hypokalemia (monitor and replace), hypechloremic non anion gap metabolic acidosis (occurs during recovery phase of DKA/usually self limited with few clinical consequences). cerebral edema (usually fatal or has serious neurological sequelae).

Question 21

what is the cause of cerebral edema in DKA?

Answer 21

unknown. too fast fluid correction, excessive bicarb, hyponatremia, too rapid glucose correction?

Question 22

which has a higher mortality? HHS/DKA

Answer 22

HHS.