DKA/HHS

Question 1

DKA vs. HHS: onset

Answer 1

DKA: hours-days
HHS: several days/weeks

Question 2

DKA vs. HHS:: clinical picture

Answer 2

Both: polyuria, polydipsia, weight loss, vomiting, dehydration, weakness, mental status changes

DKA: Kussmaul respirations, N/V, abdominal pain
HHS: neurologic manifestions

Question 3

DKA vs. HHS: glucose

Answer 3

DKA: >250
HHS: >600

Question 4

DKA vs. HHS: acidosis

Answer 4

DKA: <7.3
HHS: normalized

Question 5

DKA vs. HHS: anion gap

Answer 5

DKA: >12
HHS: variable

Question 6

DKA vs. HHS: ketones

Answer 6

DKA: positive
HHS: negative

Question 7

DKA vs. HHS: effective serum osmolality

Answer 7

DKA: <320
HHS: >320

Question 8

Precipitating factors for DKA/HHS

Answer 8

Infections, MI, medications, noncompliance with therapy, poor “sick day” management, pancreatitis, drug/alcohol abuse, inadequate dose or D/C of insulin, new onset T1DM

Question 9

Pillars of treatment in DKA/HHS (the drugs used)

Answer 9

Regular insulin
Potassium
Fluids
Bicarbonate

(also phosphate)

Question 10

IV fluids: initial management

Answer 10

15-20 ml/kg for the first hour

Question 11

IV fluids: subsequent management for severe hypovolemia

Answer 11

NS 1L/hr

Question 12

IV fluids: subsequent management for mild dehydration

Answer 12

Depends on sodium level

Normal or high: 1/2NS (250-500ml/hr) depending on hydration status
High: NS (250-500ml/hr) depending on hydration status

Question 13

To prevent hypoglycemia, what should eventually be added to IV fluids?

Answer 13

D5W

Question 14

When should D5W be added?

Answer 14

DKA: BG is 200mg/dl
HHS: BG is 300mg/dl

Change to 1/2NS D5W once BG reaches those levels

Question 15

Debate on bicarb use

Answer 15

Treating the underlying problem will treat acidosis…so why give it, you know?

Question 16

Risks with bicarbonate administration

Answer 16

increased hypokalemia risk, decrease in tissue O2 uptake, cerebral edema, paradoxical CNS acidosis

Question 17

Bicarb indications

Answer 17

Only give to patients whose pH is <6.9

100mmol sodium bicarb in 400ml water and 20mEq of KCl over 2 hours; repeat q2h until pH ≥7

Question 18

Regular insulin dosing: starts with a bolus

Answer 18

0.1 unit/kg IV bolus, then 0.1 unit/kg/hr continuous infusion

Question 19

Regular insulin dosing: no bolus

Answer 19

0.14 units/kg/hr

Question 20

Decrease the insulin infusion to ________ when the BG level is _____ in DKA, ______ in HHS.

Answer 20

Decrease the insulin infusion to 0.02-0.05 units/kg/hr when the BG level is ≤200 in DKA, ≤300 in HHS.

Question 21

Goal BG after insulin administration

Answer 21

DKA: 150-200 until resolution
HHS: 200-300 until patient is mentally alert

Question 22

Definition of DKA resolution

Answer 22

Blood glucose <200mg/dl AND 2 of the following:

serum bicarb level >15 mEq
venous pH >7.3
anion gap ≤12 mEq/L

Question 23

Definition of HHS resolution

Answer 23

Normal osmolality and mental status

Question 24

What to do with insulin when DKA/HHS has resolved

Answer 24

Initiate SQ basal insulin and overlap with IV infusion for 1-2 hours

Question 25

Initiating SQ basal insulin: patient with a history of DM and takes insulin outpatient

Answer 25

PTA dosing if it was controlling DM, but usually started off on a decreased dose

Question 26

Initiating SQ basal insulin: insulin naïve patient

Answer 26

multi dose regimen with basal (glargine and detemir) and bolus (lispro, aspart, glulisine) started at a dose of 0.5-0.8 units/kg/day, total dose split across basal and bolus

Question 27

Hypoglycemia monitoring

Answer 27

BG checks qh

Question 28

Potassium therapy: K+ level is <3.3 mEq/L

Answer 28

hold insulin, replete at 20-30mEq/hr until the K+ >3.3 mEq/L

Question 29

Potassium therapy: K+ level is 3.3-5.2 mEq/L

Answer 29

20-30 mEq should be given with every 1 liter of fluid

Question 30

Potassium therapy: K+ level is >5.2 mEq/L

Answer 30

Hold potassium until levels fall below ULN

Question 31

Phosphate therapy

Answer 31

20-30mEq/L added to replacement fluids indicated for cardiac dysfunction, anemia, respiratory depression, serum phosphate concentration <1.0mg/dl

Question 32

Hypokalemia monitoring

Answer 32

BMPs should be monitored q4-6h while insulin infusion is running

Question 33

Hyperchloremic non-anion gap metabolic acidosis

Answer 33

secondary to excess infusion of chloride continuing fluids during treatment

Question 34

Cerebral edema prevention

Answer 34

avoidance of excessive hydration and rapid reduction of plasma osmolarity
gradual decrease in serum glucose
maintaining serum glucose between 250-300 mg/dl until patient’s serum osmolality is normalized and mental status is improved

Question 35

Cerebral edema treatment

Answer 35

Mannitol infusion and mechanical ventilation