DKA/HHS

Question 1

what does DKA involve?

Answer 1

ketoacidosis and hyperglycemia

Question 2

what does HHS involve?

Answer 2

hyperglycemia without ketoacidosis

Question 3

specifics of DKA

Answer 3

–more common in people under 65
–associated with type 1 diabetes
–can occur in type 2

Question 4

specifics of HHS

Answer 4

–mostly with T2DM
–more common in individuals over 65

Question 5

normal response to hyperglycemia

Answer 5

–extracellular concentration of glucose regulated by insulin and glucagon
–when serum glucose rises, glucose enters pancreas initiating insulin release
–insulin restores normal glycemic levels by (1) diminishing hepatic glucose production and (2) increases glucose uptake by skeletal muscle and adipose tissue

Question 6

causes of hyperglycemia

Answer 6

–insulin deficiency and/or resistance
–glucagon excess
–increased catecholamines
–increased cortisol

Question 7

BG for HHS

Answer 7

can exceed 1000 mg/dL

Question 8

BG for DKA

Answer 8

generally below 800 mg/dL, often 350-450

Question 9

other symptoms of DKA

Answer 9

–often present earlier with symptoms of ketoacidosis rather than hyperosmolality
–tend to be younger and have higher GFR

Question 10

ketone production

Answer 10

–can’t get glucose into cells so body uses fat for energy
–lipolysis of peripheral fat stores releases free fatty acids and glycerol
–fatty acids are transported to liver and become “activated”
–activated fatty acids are converted to acetyl-CoA and enter ketogenic metabolic pathway forming “ketone bodies”
–accumulation of ketone bodies causes a drop in pH

Question 11

anion gap specifics with DKA/HHS

Answer 11

–DKA
–caused by production and accumulation of ketones

Question 12

severity of acidosis and increase of anion gap factors include:

Answer 12

–rate and duration of ketoacid production
–rate of metabolism of ketoacids
–rate of loss of ketoacid anions in urine

Question 13

plasma osmolality with DKA/HHS

Answer 13

–hyperglycemia pulls water out of cells, expands ECF, reducing plasma sodium
–glucosuria causes osmotic diuresis leading to excretion of sodium, potassium, and water

Question 14

potassium with DKA/HHS

Answer 14

–both have total decreased potassium levels: increased urinary loss and GI losses
–serum potassium is normal to high due to hyperosmolality and insulin deficiency

Question 15

cause of increased serum potassium in DKA/HHS

Answer 15

–increased plasma osmolality causes water to move out of calls and potassium also moves into ECF
–insulin normally promotes potassium uptake by the cells so lack = increased levels

Question 16

cellular compensation in DKA

Answer 16

INCREASE in H+ IN ACIDOSIS
–H+ move into cell
–more positively charged ions in cell
–K+ moves out of cell
–electrical neutrality is restored inside cell
–temporary correction of pH
process will reverse as pH returns to normal
–if kidneys are working, they will excrete excess K+ –> depletion

Question 17

precipitating factors for DKA/HHS

Answer 17

–infection without insulin adjustment
–acute major illness or inflammatory process
–new onset T1DM = DKA common
–drugs that affect carb metabolism (glucocorticoids, thiazide diuretics)
–use of SGLT2 inhibitors
–cocaine use or substance abuse
–poor compliance with insulin regimen or faulty SQ insulin infusion devices

Question 18

symptoms of DKA

Answer 18

–rapid onset (over 24 hours)
–polyuria, polydipsia
–GI effects
–may have neuro effects
–volume depletion (decreased skin turgor, dry oral mucosa, tachy, hypotension)
–fruity odor of breath
–Kussmaul’s respirations

Question 19

symptoms of HHS

Answer 19

–insidious
–polyuria
–polydipsia
–weight loss
–lethargy, obtunded, coma (as glucose increases)
–signs of volume depletion like DKA

Question 20

treatment of DKA/HHS

Answer 20

–fluid replacement
–correction of electrolyte imbalance
–admin of insulin by infusion
–sodium bicarb
–dextrose may be added to NS when glucose < 200 if patient still has anion gap while still on continuous insulin drip

Question 21

when is hyperglycemic crisis resolved?

Answer 21

–DKA = ketoacidosis has resolved
–HHS = patient is mentally alert and plasma osmolality has dropped to 315
–patient is able to eat and can transition back to SQ insulin

Question 22

what is DKA overall?

Answer 22

condition of ketones in the blood, metabolic acidosis leading to anion gap, and hyperglycemia associated with insulin deficiency