Exam 1 - Diabetic Ketoacidosis, Hyperosmolar/glycemic State, & Sepsis Flashcards
List precipitating factors of DKA/HHS?
infection (#1), initial presentation of diabetes, insufficient insulin therapy, pancreatitis, acute CV events, medications (glucocorticoids, atypical antipsychotics, BBs, thiazides, sympathomimetics)
List signs/symptoms of DKA?
Kussmaul respirations, acetone breath, N/V, abdominal pain, urine ketones positive, anion gap 12+
List signs/symptoms of HHS?
hypothermia, hypotension tachycardia AMS, polydipsia, polyuria, weakness, weight loss
Does DKA or HHS have a faster onset?
DKA
What is the serum sodium correction?
add 1.6 mEq Na for each 100 mg blood glucose >100 mg/dL
List the goals of treatment in DKA/HHS? (3)
hydration, correct hyperglycemia and ketosis, fix electrolyte imbalances
What is initial treatment for dehydration in DKA/HHS?
500-1000 mL/hr of NS (or 1/2 NS if high Na) or lactated ringers in first 2 hrs
What is initial treatment for hyperglycemia and ketosis in DKA/HHS?
0.1 units/kg IV bolus insulin, followed by 0.1 units/kg/hr
What is treatment for hyperglycemia and ketosis once DKA/HHS has been initially treated?
decrease IV infusion (0.02-0.05 units/kg/hr) and switch to dextrose-containing IV fluids until resolved
What is treatment for K+ values <3.3 mEq/L?
hold insulin and give 10-20 mEq/hr K+ until >3.3
What is treatment for K+ values 3.3-5.2 mEq/L?
give 20-30 mEq K+ in each liter of IV fluid
What is treatment for K+ values >5.2 mEq/L?
do NOT give K+, but check serum every 2 hrs
When is bicarbonate indicated in DKA/HHS?
if pH <6.9
What are goals in DKA treatment?
BG < 200 mg/dL plus at least 2 of the following: serum bicarbonate 15+ mEq/L, pH >7.3, anion gap 12 or less mEq/L
What are goals in HHS treatment?
serum osmolality <320 mOsm/kg, recovery to mental alertness
How should transitioning to subcutaneous insulin be performed?
only once hyperglycemic crisis resolved and patient is able to eat, IV insulin should be continued for 2 hours after basal insulin administration, may consider resuming home regimen, new regimen start 0.4-0.5 units/kg/day with 40-50% of TDD given as basal insulin with remainder as prandial
What are common complications of treatment in DKA/HHS? (3)
hypoglycemia, hypokalemia, cerebral edema
What are the criteria for qSOFA rapid bedside score? (3)
at least two of the following: SBP < 100 mmHg, RR > 22, AMS
What are the SIRS criteria? (4)
at least two of the following: temp <36 or >38, HR >90, RR >20, WBC <4 or >12 x10^9/L
List drawbacks of unnecessary antimicrobial therapy?
allergic reactions, AKI, thrombocytopenia, C. difficile infections, antimicrobial resistance
List risk factors that warrant MRSA coverage?
Hx of MRSA, recent IV abx, Hx recurrent skin infections or chronic wounds, invasive devices, hemodialysis, recent hospital admissions, severity of illness
List risk factors that warrant double gram negative coverage as empiric therapy?
Hx of infection with resistant organisms (<1 year), broad spectrum IV abx (<90 days), endemic travel (<90 days), local prevalence, hospital acquired infections
What are the goals for fluid therapy in sepsis?
increase stroke volume, cardiac output, and oxygen delivery
What is fluid therapy for sepsis?
IV crystalloids (LR/NS) 30 mL/kg over 15-30 minutes, followed by 10 mL/kg boluses PRN (NO CONTINUOUS INFUSIONS)
What is an AE of lactated ringers?
may produce hyponatremia
What are AEs of normal saline?
may produce hypernatremia, hyperchloremia, and metabolic acidosis (AKI risk)
Albumin 5% is used for _____, while albumin 25% is used for ______?
fluid resuscitation, fluid mobilization
What is not recommended for resuscitation in septic shock?
starches
Explain the results of the SAFE and ALBIOS trials?
No difference in days spent in ICU when comparing 4% albumin to normal saline in sepsis treatment…don’t use albumin upfront
What is the first-line vasopressor for septic shock?
norepinephrine
What is the second-line vasopressor for septic shock?
vasopressin (if MAP still <65 mmHg)
When is dobutamine a good option for septic shock?
presenting with cardiogenic shock symptoms as well
Which medications are not recommended in septic shock? (2)
angiotensin II, phenylephrine
Which steroids are added on to help with refractory shock?
hydrocortisone, fludrocortisone (more mineralocorticoid activity)
When are steroids added on to help in septic shock?
when it is considered refractory and there is an ongoing need for vasopressors
