DKA/HHS

Question 1

general pathogenesis

Answer 1

reduction of circulating insulin
elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, growth hormones)

Question 2

pathophysiology of DKA

Answer 2

precipitating factors eventually leads to triglycerides –> glycerol and free fatty acids –> ketones

Question 3

DKA – goals of treatment

Answer 3

restore circulatory volume
inhibit ketogenesis and return of normal glucose metabolism
correct electrolyte imbalances

Question 4

DKA – IV insulin initiation

Answer 4

start 0.1 units/kg/hour +/- a bolus of 0.1 units/kg

Question 5

DKA – IV insulin continuation

Answer 5

when plasma glucose reaches 200 mg/dL
- decrease infusion rate to 0.02 to 0.05 units/kg/hr
- change fluids from NS to 1/2 NS + D5W
- decrease fluid rate to 150 - 250 mL/hour

Question 6

DKA – transitioning insulin

Answer 6

blood glucose level below 200 mg/dL AND need two of the following:
- anion group closes
- bicarbonate level above 15
- venous pH above 7.3

Question 7

DKA – transitioning insulin in naive patient

Answer 7

start basal/bolus regimen of a TDD of 0.5 to 0.8 units/kg/day divided 50/50 between basal and bolus

Question 8

DKA – transitioning insulin in insulin-dependent patient

Answer 8

add up total amount of IV insulin required by patient
convert to estimated daily requirement using basal/bolus or every 6 hours NPH insulin

Question 9

DKA – transitioning insulin RULE

Answer 9

overlap IV and SQ by 2-4 hours to prevent rebound ketoacidosis and hyperglycemia

Question 10

anion gap equation

Answer 10

Na - (Chloride + Bicarbonate)

Question 11

anion gap closure

Answer 11

when under 12
can consider transitioning from IV to SQ insulin

Question 12

when should insulin not be started?

Answer 12

when potassium is under 3.3 mmol/L

Question 13

DKA – potassium

Answer 13

maintain a K of 4-5 mmol/L
anything above 5 is considered acidosis and needs to be corrected with fluids and insulin

Question 14

euglycemic DKA

Answer 14

rare form of DKA where bg is normal/slightly elevated but still urine positive for ketones
may be caused by SGLT2 inhibitors

Question 15

DKA symptoms

Answer 15

NV
abdominal cramps
dehydration
polys
AMS
coma

Question 16

DKA patients

Answer 16

new diagnosis T1DM
non-adherence to insulin
possible infection

Question 17

DKA labs

Answer 17

pH < 7.3 with AG
low bicarbonate
+ B-HB/ketones
elevated K+
low Na+
elevated glucose

Question 18

DKA initial treatment

Answer 18

0.9% NaCl (or LR) + IV insulin drip + electrolyte replacement

Question 19

DKA further management

Answer 19

add D5 to IV fluids
transition to SQ insulin when criteria met
continue to monitor electrolytes

Question 20

HHS – pathophysi

Answer 20

insulin deficiency or resistance eventually leads to hyperosmolality and mental confusion, coma, and seizures

Question 21

HHS patients

Answer 21

older adults
underlying heart failure or kidney disease
precipitating factors –> heart attack, stroke, infection, recent procedure
precipitating drugs –> phenytoin, corticosteroids, diuretics

Question 22

HHS presentation

Answer 22

weakness –> polyuria, polydipsia, dehydration
severe –> confusion, coma, seizures

Question 23

osmolality equation

Answer 23

(Na x 2) + (BUN/2.8) + (glucose/18)

Question 24

HHS – goals of treatment

Answer 24

restore circulatory volume
restore urine output to 50mL/hour or more
return bg to normal

Question 25

HHS initial treatment

Answer 25

administer 0.45 NS

Question 26

HHS further treatment

Answer 26

when blood glucose is 300 mg/dL
- change to D5W with 0.45 NS
- rate of 150 to 250 mL/hr until resolution

Question 27

corrected sodium equation

Answer 27

measured sodium + 1.6[ (glucose-100)/100]

Question 28

HHS – IV insulin initiation

Answer 28

initial glucose goal of 300 mg/dL at 0.1 units/kg/hour +/- a bolus of 0.1 units/kg

Question 29

HHS – IV insulin continuation

Answer 29

decrease infusion to maintain a glucose of 200-300 mg/dL until patient is mentally alert then transition to SQ insulin (2-4 hours overlap)

Question 30

HHS - electrolyte monitoring

Answer 30

sodium –> during fluid resuscitation
phosph –> only supplement if < 1 mg/dL
potassium –> not large problem, may supplement prn

Question 31

complications of DKA + HHS

Answer 31

cerebral edema
hypoglycemia

Question 32

general rules of follow-up

Answer 32

ensure patient has proper follow-up with endocrinologist, PCP, pharmacist, dietician, etc
assess ability to pay for medication
education on discharge diabetes regimen
PREVENT READMISSION

Question 33

glucose lab differences

Answer 33

over 250 in all forms of DKA
over 600 in HHS

Question 34

bicarbonate lab differences

Answer 34

15-18 mild DKA
10-14 moderate DKA
under 10 severe DKA
normal HHS

Question 35

urine/blood acetoacetate lab differences

Answer 35

positive DKA
minimal to none HHS

Question 36

fluid treatment main differences

Answer 36

DKA –> 0.9 NaCl or balanced crystalloid at initiation; serum glucose needs to hit 200 mg/dL

HHS –> 0.45 NaCl at initiation; serum glucose needs to hit 300 mg/dL

Question 37

insulin treatment main differences

Answer 37

DKA –> reach BG of 200 mg/dL; maintain glucose of 150 to 200 mg/dL until resolution; transition to SQ when criteria met

HHS –> reach BG of 300 mg/dL; maintain glucose of 200 to 300 mg/dL; transition to SQ when mental alert

Question 38

general rule of IV to SQ transition

Answer 38

need a 2 to 4 hour overlap

Question 39

DKA – potassium additions

Answer 39

add 20 mEq/L at 4-5
add 40 mEq/L at 3-4
at < 3, add 10-20 mEq/hour until K is greater

Question 40

DKA – bicarbonate additions

Answer 40

give if pH is under 6.9
50 to 100 mmol of bicarbonate every 1-2hours until pH is above