Endocrine/Electrolyte

Question 1

DKA and HHS represent a spectrum of complications from DM and differ mainly in what 3 ways?

Answer 1

Level of hyperglycemia
Extent of dehydration
Presence and degree of ketoacidosis

Question 2

Contrast the populations presenting with DKA vs. HHS.

Answer 2

DKA: younger patients (<65 y/o) with DM1, usually evolves rapidly over 24 hours

HHS: older patients (>65 y/o) with DM2, evolves over several days

Question 3

Define hyperglycemia.

Answer 3

Fasting (8 hrs): >90-130 mg/dL

Postprandial >180 mg/dL

Question 4

Describe DKA and its common causes.

Answer 4

Absolute insulin deficiency, hyperglycemia, AG acidosis, dehydration

Infection, disruption of insulin therapy, presentation of new onset DM

Question 5

Describe HHS and its common causes.

Answer 5

Hyperglycemia
Hyperosmolarity
Dehydration
WITHOUT significant ketoacidosis

Poorly controlled DM2 with underlying infection

Question 6

Which has a higher mortality rate - HHS or DKA?

Answer 6

HHS

Question 7

Initial actions/primary survey in hyperglycemia/HHS/DKA?

Answer 7

Mild to moderate hyperglycemia/minor symptoms - anticipatory guidance and proper follow-up

BG>300-350: UA (ketones?), then BMP to exclude AG acidosis, +/- IVF

Ill-appearing, hemodynamically unstable/DKA/HHS - ABCs, 2 large bore IVs, normal saline 1-2L (adult), bolus 20 cc/kg (child), monitor

Question 8

What conditions can affect diabetic patients resulting in an increase in counter-regulatory hormones and hyperglycemia and precipitate DKA/HHS?

Answer 8

Cocaine use
Infection/sepsis
MI
Surgery
Trauma

Question 9

Classic presentation of hyperglycemia?

Answer 9

Mild - asymptomatic
BG>180 mg/dL - osmotic diuresis; polyuria, polydipsia, polyphagia, weight loss
Some will have tachycardia, dizziness, lightheadedness, and weakness as a result of dehydration/lyte imbalance

Progression - abdominal pain, hyperpneic respirations (fast and deep Kaussmaul respirations), hypotension, ketotic breath, marked tachycardia, neuro symptoms (HHS)

Question 10

Lab tests for hyperglycemia/DKA/HHS?

Answer 10

POC glucose
UA
BMP
CBC
VBG
Phos, Mag
EKG
Additional testing based on patient presentation (lipase, hepatic functions, CXR, BCx, etc.)

Question 11

Lab findings in DKA?

Answer 11

Glucose: >250
Arterial pH: <7.3
Serum bicarb: <18
Urine ketones: +++
Serum ketones: +++
Serum Osm: increased
AG: >>>12
Mental status: variable

Question 12

Lab findings in HHS?

Answer 12

Glucose: >600
Arterial pH: >7.3
Serum bicarb: >18
Urine ketones: -/faintly +
Serum ketones: -/faintly +
Serum Osm: very increased
AG: Normal (12-16)
Mental status: stupor/coma

Question 13

Rx uncomplicated mild to moderate hyperglycemia?

Answer 13

IV fluids

Question 14

Rx DKA and HHS?

Answer 14

Fluid replacement
Management of electrolyte abnormalities
Insulin replacement therapy
ID underlying precipitants

Question 15

How is fluid replacement done in DKA/HHS?

Answer 15

Avg loss in DKA 3-6 L, HHS 8-10 L
Start with NS at 15-20 mL/kg/hr for the first few hours
Switch to 0.45% saline when the serum sodium normalizes
Add dextrose to IV fluids when serum glucose reaches 250 mg/dL

Question 16

Insulin replacement in DKA/HHS?

Answer 16

Start only after adequate fluid resuscitation
Start with an infusion of regular insulin at 0.1 U/kg/hr
Double the dose of insulin if the blood glucose does not fall by 50-70 mg/dL in the first hour

Question 17

Potassium replacement in DKA/HHS?

Answer 17

If initial K <3.3 mEq/L then DELAY insulin therapy until fluid and K replacement

Give K with initial fluid replacement if K levels are normal or low and maintain between 4-5

Question 18

Use of bicarb in DKA/HHS?

Answer 18

Controversial, as it may cause a paradoxical fall in cerebral pH and neuro deterioration

Certain situations may warrant use:
Severe acidosis with pH <6.9
Severe life-threatening hyperkalemia
Seizures
Cardiac or persistently hypotensive patient

Question 19

Serial monitoring in DKA/HHS?

Answer 19

BG every hour until stable, then every 2-4 hours

BMP and blood pH Q2-4 hours during therapy until stabilized