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Endocrine-Week 3/4 > DKA & HHS > Flashcards

DKA & HHS Flashcards

1
Q

Complication of Type 1 Diabetes; usually due to missed/inadequate doses of Insulin, infection, or other stressor –> insufficient insulin –> high BG and acid formation; unchecked glycogenolysis, gluconeogenesis and ketogenesis; production of ketones resulting in metabolic acidosis and hyperventilation; mortality is highest in YOUNG

A

Diabetic Ketoacidosis

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2
Q

Diabetic Ketoacidosis is usually seen in type (1/2) diabetics

A

Type 1

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3
Q

Diabetic Ketoacidosis has a high mortality in the (young/elderly)

A

Young

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4
Q

What medication requires increased insulin requirement, leading to DKA?

A

steroids

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5
Q

What drug requires increased insulin requirement, leading to DKA?

A

Cocaine

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6
Q

What counterregulatory hormones require increased insulin requirement, leading to DKA?

A

glucagon
cortisol
catecholamines

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7
Q

Symptoms of Diabetic Ketoacidosis

A 
Thirst
Polyuria
Weakness
SOB
Abdominal pain
Nausea/vomiting
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8
Q

Physical exam findings of Diabetic Ketoacidosis

A 
Tachycardia
Hypotension
Orthostasis
Dry membranes/poor skin turgor
Hypothermia
** Kussmaul respirations (fruity breath)
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9
Q

Lab findings of Diabetic Ketoacidosis

A
  • Elevated BG
  • Positive serum and urine ketones
  • Decreased HCO3, Increased AG
  • pCO2 <40
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10
Q

Kussmaul respirations are characterized as (shallow/deep) and (rapid/slow) breaths

A

Deep and Rapid

*early on, can be shallow

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11
Q

Pathogenesis of Diabetic Ketoacidosis

A
  1. Insulin deficiency
  2. Glycogenolysis and gluconeogenesis–> HYPERGLYCEMIA–> osmotic diuresis–> dehydration
  3. Lipolysis –> Ketogenesis–> anion gap metabolic acidosis
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12
Q

3 MOA of the body against acidosis

A
  1. Kidney
    - Excretion of ketone bodies
    - Buffer ketone bodies
  2. Blood
    - Serum bicarbonate, bone, and intracellular proteins buffer hydrogen ions
  3. Lung
    - acidosis stimulates hyperventilation, and this blows off CO2
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13
Q

Because of the body’s defenses against acidosis –> ketone bodies are present initially in ____ without high blood levels, then later in higher concentrations in _____ without actual fall of arterial pH (due to serum bicarbonate)

A
  • urine

- blood

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14
Q

When the body’s defenses against acidosis eventually fail, what characteristic picture occurs?

A
  • Low bicarbonate
  • Low pCO2
  • Low arterial pH
  • High anion gap
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15
Q

The sum of measured cations minus measured anions

A

anion gap

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16
Q

In normal anion gap, what represents unmeasured anions in the blood?

A

negatively charged phosphates and sulfates

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17
Q

In DKA, anion gap represents what unmeasured anions in the blood?

A

ketone bodies

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18
Q

The best indicator of SEVERITY of the DKA

A

Anion gap

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19
Q

Closing or normalization of ______ is the best indicator of successful treatment for DKA

A

Anion gap

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20
Q

Equation for Anion Gap

A

Na - (Cl + HCO3)

*should be less than or equal to 12

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21
Q

The Anion Gap should be less than or equal to

A

12

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22
Q

severity of (acidosis/hyperglycemia) is the best indicator of of the severity or the successful treatment of DKA

A

acidosis (pH, AG)

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23
Q

pH, HCO3, and Anion gap for MILD DKA

A

pH: 7.25-7.3
HCO3: 15-18
Anion Gap: >10

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24
Q

pH, HCO3, and Anion gap for MODERATE DKA

A

pH: 7.0-7.24
HCO3: 10-14
Anion Gap: >12

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25
Q

pH, HCO3, and Anion gap for SEVERE DKA

A

pH: <7.0
HCO3: <10
Anion Gap: >12

26
Q

Examples of ketones

A

Acetone
Acetoacetate
B-hydroxybutyrate

27
Q

Lab test that can be used to measure ketones

A

Nitroprusside Reaction

  • Detects ONLY acetone and acetoacetate
28
Q

Which ketone is NOT measured by the Nitroprusside reaction

A

B-hydroxybutyrate

the one that predominates in DKA

29
Q

Which ketone predominates in DKA but doesn’t get measured by Nitroprusside Reaction?

A

B-hydroxybutyrate

30
Q

What ketone is not an acid but can cause fruity smell?

A

Acetone

31
Q

Why is severity of DKA measured by AG and not by amount of ketones?

A
  1. Nitroprusside reaction detects only acetone and acetoacetate but NOT B-hydroxybutyrate
  2. Acetoacetate can be dominant in recovery and therefore be misleading
32
Q

Complication of Type 2 Diabetes; usually due to missed/inadequate doses of Insulin, infection, or other stressor –> insufficient insulin –> VERY high BG and Osmolality + DEHYDRATION; can result in confusion and dizziness; mortality is highest in ELDERLY

A

Hyperglycemic Hyperosmolar State (HHS)

33
Q

What medications can cause HHS?

A

** corticosteroids
thiazides
Phenytoin (anticonvulsant)

** most common

34
Q

What precipitating factors/comorbidities can cause HHS?

A
  • Infection
  • Thromboses
  • Hemorrhage
  • Burn
  • Pancreatitis
  • Renal failure
35
Q

Signs/Symptoms of HHS

A 
Thirst/Dehydration
Dementia/AMS
High BG
High serum Osm
Hypotension
36
Q

Hyperglycemic Hyperosmolar States are more common in type (1/2) diabetics

A

Type 2

37
Q

Hyperglycemic Hyperosmolar State has a high mortality in the (young/elderly)

A

Elderly

38
Q

Pathogenesis of HHS

A
  1. Insulin deficiency
  2. Glycogenolysis and gluconeogenesis–> HYPERGLYCEMIA –> osmotic diuresis–> dehydration –> decreased fluid intake –> HYPEROSMOLARITY
39
Q

DKA/HHS has greater severity of dehydration, hyperglycemia, hypernatremia, and hyperosmolality

A

HHS

40
Q

(T/F) Ketogenesis in HHS is sufficient to produce a medically significant metaboilc acidosis

A

False

41
Q

Measure of the number of dissolved particles (solute) per unit of water (solvent) in serum; the concentration of an osmotic solution

A

Serum osmolality

42
Q

Equation for Serum Osmolality

A

2 x Na + glucose/18 + BUN/3

  • Normal is 285-295 mosm/L
43
Q

Normal Serum Osmolality

A

285-295 mOsm/L

44
Q

What is the best indicator of severity of HHS?

A

degree of hyperosmolality

45
Q

BG, pH, HCO3, and serum Osm for HHS

A

BG: Very High (>600)
pH: >7.3
HCO3: >18
Osm: >320 mOsm/kg

46
Q

The mortality of (DKA/HHS) is higher

A

HHS because of the coexistence of a serious underlying precipitating illness (seizures, thromboses, embolism, etc.)

47
Q

Treatment for DKA and HHS

A

**fix dehydration FIRST!

  • Volume replacement (isotonic-0.9% NaCl –> hypotonic-0.45 –> 5% dextrose w/ 0.45% NaCl + insulin)
  • Insulin
  • POTASSIUM (arrhythmias)
48
Q

What diabetes therapy can cause elevated anion gap with normal blood glucose, urinary frequency, and abdominal pain?

A

SGLT-2 inhibitor therapy

49
Q

Why is potassium so fickle during DKA

A

Acidosis causes potassium to shift OUT of cells, showing hyperkalemia (masking the overall deficit)

Insulin then causes potassium to reenter cell, possibly causing life-threatening hypokalemia

50
Q

What are causes of Morbidity/Mortality in DKA and HHS

A

Iatragenic: (due to fluid resuscitation)

  • Cerebral edema
  • Hypoglycemia
  • Hypokalemia
  • Hypophosphatemia

End-Organ Problems:

  • Acute Renal failure
  • ARDS
  • Vascular Thrombosis
  • Sepsis
51
Q

When do you switch to 5% dextrose w/ 0.45% NaCl in DKA patients?

A

When serum glucose reaches 200 mg/dL

52
Q

When do you switch to 5% dextrose w/ 0.45% NaCl in HHS patients?

A

When serum glucose reaches 300 mg/dL

53
Q

When do you give 20-30 mEq of K+ in each liter of IV fluid to keep serum K b/w 4-5 mEq/L?

A

when serum K+ is 3.3 to 5.3 mEq/L

54
Q

When do you hold insulin and give 20-40 mEq of K+ per hour until K+ > 3.3 mEq/L?

A

when serum K+ is < 3.3 mEq/L

55
Q

When is K+ not needed but serum K+ must be checked every 2 hours?

A

when serum K+ is > 5.3 mEq/L

56
Q

How much insulin should be given for DKA and HHS patients?

A

Regular insulin 0.1 units/kg as IV bolus

57
Q

When do you reduce regular insulin infusion to 0.02-0.05 units/kg for DKA patients?

A

when serum glucose reaches 200 mg/dL

58
Q

When do you reduce regular insulin infusion to 0.02-0.05 units/kg for HHs patients?

A

when serum glucose reaches 300 mg/dL

59
Q

When do you give bicarbonate for DKA patients?

A

when pH is <6.9

60
Q

Triglycerides are utilized to produce what forms of energy? (2 total)

A

Free fatty acids

Ketones

61
Q

What are other triggers of Ketosis, besides Diabetic Ketoacidosis

A

Alcohol
Starvation
Isopropyl alcohol

62
Q

What are other triggers of acidosis, besides Diabetic Ketoacidosis

A

Lactic acid
Alcohol (ETOH, methanol, ethylene glycol)
Salicylates

Endocrine-Week 3/4 (9 decks)

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