DKA/HHS Flashcards
DKA vs. HHS: onset
DKA: hours-days
HHS: several days/weeks
DKA vs. HHS:: clinical picture
Both: polyuria, polydipsia, weight loss, vomiting, dehydration, weakness, mental status changes
DKA: Kussmaul respirations, N/V, abdominal pain
HHS: neurologic manifestions
DKA vs. HHS: glucose
DKA: >250
HHS: >600
DKA vs. HHS: acidosis
DKA: <7.3
HHS: normalized
DKA vs. HHS: anion gap
DKA: >12
HHS: variable
DKA vs. HHS: ketones
DKA: positive
HHS: negative
DKA vs. HHS: effective serum osmolality
DKA: <320
HHS: >320
Precipitating factors for DKA/HHS
Infections, MI, medications, noncompliance with therapy, poor “sick day” management, pancreatitis, drug/alcohol abuse, inadequate dose or D/C of insulin, new onset T1DM
Pillars of treatment in DKA/HHS (the drugs used)
Regular insulin
Potassium
Fluids
Bicarbonate
(also phosphate)
IV fluids: initial management
15-20 ml/kg for the first hour
IV fluids: subsequent management for severe hypovolemia
NS 1L/hr
IV fluids: subsequent management for mild dehydration
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
To prevent hypoglycemia, what should eventually be added to IV fluids?
D5W
When should D5W be added?
DKA: BG is 200mg/dl
HHS: BG is 300mg/dl
Change to 1/2NS D5W once BG reaches those levels
Debate on bicarb use
Treating the underlying problem will treat acidosis…so why give it, you know?
Risks with bicarbonate administration
increased hypokalemia risk, decrease in tissue O2 uptake, cerebral edema, paradoxical CNS acidosis
Bicarb indications
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
Regular insulin dosing: starts with a bolus
0.1 unit/kg IV bolus, then 0.1 unit/kg/hr continuous infusion
Regular insulin dosing: no bolus
0.14 units/kg/hr
Decrease the insulin infusion to ________ when the BG level is _____ in DKA, ______ in HHS.
Decrease the insulin infusion to 0.02-0.05 units/kg/hr when the BG level is ≤200 in DKA, ≤300 in HHS.
Goal BG after insulin administration
DKA: 150-200 until resolution
HHS: 200-300 until patient is mentally alert
Definition of DKA resolution
Blood glucose <200mg/dl AND 2 of the following:
serum bicarb level >15 mEq
venous pH >7.3
anion gap ≤12 mEq/L
Definition of HHS resolution
Normal osmolality and mental status
What to do with insulin when DKA/HHS has resolved
Initiate SQ basal insulin and overlap with IV infusion for 1-2 hours
Initiating SQ basal insulin: patient with a history of DM and takes insulin outpatient
PTA dosing if it was controlling DM, but usually started off on a decreased dose
Initiating SQ basal insulin: insulin naïve patient
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
Hypoglycemia monitoring
BG checks qh
Potassium therapy: K+ level is <3.3 mEq/L
hold insulin, replete at 20-30mEq/hr until the K+ >3.3 mEq/L
Potassium therapy: K+ level is 3.3-5.2 mEq/L
20-30 mEq should be given with every 1 liter of fluid
Potassium therapy: K+ level is >5.2 mEq/L
Hold potassium until levels fall below ULN
Phosphate therapy
20-30mEq/L added to replacement fluids indicated for cardiac dysfunction, anemia, respiratory depression, serum phosphate concentration <1.0mg/dl
Hypokalemia monitoring
BMPs should be monitored q4-6h while insulin infusion is running
Hyperchloremic non-anion gap metabolic acidosis
secondary to excess infusion of chloride continuing fluids during treatment
Cerebral edema prevention
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
Cerebral edema treatment
Mannitol infusion and mechanical ventilation
