DKA/HHS Flashcards
hebenstreit
general pathogenesis
reduction of circulating insulin
elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, growth hormones)
pathophysiology of DKA
precipitating factors eventually leads to triglycerides –> glycerol and free fatty acids –> ketones
DKA – goals of treatment
restore circulatory volume
inhibit ketogenesis and return of normal glucose metabolism
correct electrolyte imbalances
DKA – IV insulin initiation
start 0.1 units/kg/hour +/- a bolus of 0.1 units/kg
DKA – IV insulin continuation
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
DKA – transitioning insulin
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
DKA – transitioning insulin in naive patient
start basal/bolus regimen of a TDD of 0.5 to 0.8 units/kg/day divided 50/50 between basal and bolus
DKA – transitioning insulin in insulin-dependent patient
add up total amount of IV insulin required by patient
convert to estimated daily requirement using basal/bolus or every 6 hours NPH insulin
DKA – transitioning insulin RULE
overlap IV and SQ by 2-4 hours to prevent rebound ketoacidosis and hyperglycemia
anion gap equation
Na - (Chloride + Bicarbonate)
anion gap closure
when under 12
can consider transitioning from IV to SQ insulin
when should insulin not be started?
when potassium is under 3.3 mmol/L
DKA – potassium
maintain a K of 4-5 mmol/L
anything above 5 is considered acidosis and needs to be corrected with fluids and insulin
euglycemic DKA
rare form of DKA where bg is normal/slightly elevated but still urine positive for ketones
may be caused by SGLT2 inhibitors
DKA symptoms
NV
abdominal cramps
dehydration
polys
AMS
coma
DKA patients
new diagnosis T1DM
non-adherence to insulin
possible infection
DKA labs
pH < 7.3 with AG
low bicarbonate
+ B-HB/ketones
elevated K+
low Na+
elevated glucose
DKA initial treatment
0.9% NaCl (or LR) + IV insulin drip + electrolyte replacement
DKA further management
add D5 to IV fluids
transition to SQ insulin when criteria met
continue to monitor electrolytes
HHS – pathophysi
insulin deficiency or resistance eventually leads to hyperosmolality and mental confusion, coma, and seizures
HHS patients
older adults
underlying heart failure or kidney disease
precipitating factors –> heart attack, stroke, infection, recent procedure
precipitating drugs –> phenytoin, corticosteroids, diuretics
HHS presentation
weakness –> polyuria, polydipsia, dehydration
severe –> confusion, coma, seizures
osmolality equation
(Na x 2) + (BUN/2.8) + (glucose/18)
HHS – goals of treatment
restore circulatory volume
restore urine output to 50mL/hour or more
return bg to normal
HHS initial treatment
administer 0.45 NS
HHS further treatment
when blood glucose is 300 mg/dL
- change to D5W with 0.45 NS
- rate of 150 to 250 mL/hr until resolution
corrected sodium equation
measured sodium + 1.6[ (glucose-100)/100]
HHS – IV insulin initiation
initial glucose goal of 300 mg/dL at 0.1 units/kg/hour +/- a bolus of 0.1 units/kg
HHS – IV insulin continuation
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)
HHS - electrolyte monitoring
sodium –> during fluid resuscitation
phosph –> only supplement if < 1 mg/dL
potassium –> not large problem, may supplement prn
complications of DKA + HHS
cerebral edema
hypoglycemia
general rules of follow-up
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
glucose lab differences
over 250 in all forms of DKA
over 600 in HHS
bicarbonate lab differences
15-18 mild DKA
10-14 moderate DKA
under 10 severe DKA
normal HHS
urine/blood acetoacetate lab differences
positive DKA
minimal to none HHS
fluid treatment main differences
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
insulin treatment main differences
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
general rule of IV to SQ transition
need a 2 to 4 hour overlap
DKA – potassium additions
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
DKA – bicarbonate additions
give if pH is under 6.9
50 to 100 mmol of bicarbonate every 1-2hours until pH is above
