DKA & HHS

Question 1

What can precipitate DKA?

Answer 1

Infection/Illness
Stopping insulin
New onset T1DM

Question 2

How does DKA present?

Answer 2

Vomiting
Abdominal pain
Decreasing consciousness
Dehydration
Ketotic breath (Acetone)
Hyperventilation

Question 3

How do you diagnose DKA?

Answer 3

Acidosis pH 2+ ketones on dipstick

Question 4

What investigations can be done for a patient with suspected DKA?

Answer 4

Urinalysis - Ketones
Microscopy, Culture+ sensitivity
BM glucose + ketones
Venous blood gas acidosis + K+
Bloods - U+Es, FBC, glucose, cultures

Question 5

What happens to Na+ concentrations in DKA?

Answer 5

Hyponatraemia normal as it is compensation for hyperglycaemia. Increase in Na+ suggests severe dehydration

Question 6

Why can’t you rapidly decrease insulin once the glucose has normalised when treating DKA?

Answer 6

Glucose decreases faster than ketones

Insulin is needed to remove ketones

Question 7

Why are some patients at risk of hyperchloraemic metabolic acidosis after treatment for DKA?

Answer 7

Excretion of ketones causes loss of bicarbonate

Question 8

What are the complications of DKA?

Answer 8

Cerebral oedema due to excess fluid administration
Hypokalaemia
Aspiration pneumonia
Hypophosphataemia → resp and skeletal muscle
weakness
Thromboembolism

Question 9

What is the general management of DKA?

Answer 9

HDU
G - Gastric aspiration
R - Rehydration
I - Insulin infusion
P - Potassium replacement (If low due to insulin therapy - insulin makes K+ go into cells)

Question 10

What is the specific management of DKA?

Answer 10

1L NaCl solution over 1hr if BP >90 (

Question 11

When can you swap a patient back to SC insulin after DKA?

Answer 11

Biochemically resolved
Eating
Long acting insulin started the night before

Question 12

What is the presentation of HHS?

Answer 12

T2DM patient
Longer onset eg 1 week
Can be first presentation
Dehydration
BM >35
No ketogenesis so not acidotic
High osmolality
Precipitated by infection/illness

Question 13

What are the complications of HHS?

Answer 13

Occlusive events are common eg DVT, stroke

- Give LMWH

Question 14

What is the management of HHS?

Answer 14

Rehydrate with NaCl solution over 48 hours, may need up to 9L
Wait 1hr before starting insulin as may not need it
- Titrate slowly to avoid rapid changes in osmolality
Look for precipitant eg MI, Infection, Bowel infarct