Exam 1 - Diabetic Ketoacidosis, Hyperosmolar/glycemic State, & Sepsis

Question 1

List precipitating factors of DKA/HHS?

Answer 1

infection (#1), initial presentation of diabetes, insufficient insulin therapy, pancreatitis, acute CV events, medications (glucocorticoids, atypical antipsychotics, BBs, thiazides, sympathomimetics)

Question 2

List signs/symptoms of DKA?

Answer 2

Kussmaul respirations, acetone breath, N/V, abdominal pain, urine ketones positive, anion gap 12+

Question 3

List signs/symptoms of HHS?

Answer 3

hypothermia, hypotension tachycardia AMS, polydipsia, polyuria, weakness, weight loss

Question 4

Does DKA or HHS have a faster onset?

Answer 4

DKA

Question 5

What is the serum sodium correction?

Answer 5

add 1.6 mEq Na for each 100 mg blood glucose >100 mg/dL

Question 6

List the goals of treatment in DKA/HHS? (3)

Answer 6

hydration, correct hyperglycemia and ketosis, fix electrolyte imbalances

Question 7

What is initial treatment for dehydration in DKA/HHS?

Answer 7

500-1000 mL/hr of NS (or 1/2 NS if high Na) or lactated ringers in first 2 hrs

Question 8

What is initial treatment for hyperglycemia and ketosis in DKA/HHS?

Answer 8

0.1 units/kg IV bolus insulin, followed by 0.1 units/kg/hr

Question 9

What is treatment for hyperglycemia and ketosis once DKA/HHS has been initially treated?

Answer 9

decrease IV infusion (0.02-0.05 units/kg/hr) and switch to dextrose-containing IV fluids until resolved

Question 10

What is treatment for K+ values <3.3 mEq/L?

Answer 10

hold insulin and give 10-20 mEq/hr K+ until >3.3

Question 11

What is treatment for K+ values 3.3-5.2 mEq/L?

Answer 11

give 20-30 mEq K+ in each liter of IV fluid

Question 12

What is treatment for K+ values >5.2 mEq/L?

Answer 12

do NOT give K+, but check serum every 2 hrs

Question 13

When is bicarbonate indicated in DKA/HHS?

Answer 13

if pH <6.9

Question 14

What are goals in DKA treatment?

Answer 14

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

Question 15

What are goals in HHS treatment?

Answer 15

serum osmolality <320 mOsm/kg, recovery to mental alertness

Question 16

How should transitioning to subcutaneous insulin be performed?

Answer 16

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

Question 17

What are common complications of treatment in DKA/HHS? (3)

Answer 17

hypoglycemia, hypokalemia, cerebral edema

Question 18

What are the criteria for qSOFA rapid bedside score? (3)

Answer 18

at least two of the following: SBP < 100 mmHg, RR > 22, AMS

Question 19

What are the SIRS criteria? (4)

Answer 19

at least two of the following: temp <36 or >38, HR >90, RR >20, WBC <4 or >12 x10^9/L

Question 20

List drawbacks of unnecessary antimicrobial therapy?

Answer 20

allergic reactions, AKI, thrombocytopenia, C. difficile infections, antimicrobial resistance

Question 21

List risk factors that warrant MRSA coverage?

Answer 21

Hx of MRSA, recent IV abx, Hx recurrent skin infections or chronic wounds, invasive devices, hemodialysis, recent hospital admissions, severity of illness

Question 22

List risk factors that warrant double gram negative coverage as empiric therapy?

Answer 22

Hx of infection with resistant organisms (<1 year), broad spectrum IV abx (<90 days), endemic travel (<90 days), local prevalence, hospital acquired infections

Question 23

What are the goals for fluid therapy in sepsis?

Answer 23

increase stroke volume, cardiac output, and oxygen delivery

Question 24

What is fluid therapy for sepsis?

Answer 24

IV crystalloids (LR/NS) 30 mL/kg over 15-30 minutes, followed by 10 mL/kg boluses PRN (NO CONTINUOUS INFUSIONS)

Question 25

What is an AE of lactated ringers?

Answer 25

may produce hyponatremia

Question 26

What are AEs of normal saline?

Answer 26

may produce hypernatremia, hyperchloremia, and metabolic acidosis (AKI risk)

Question 27

Albumin 5% is used for _____, while albumin 25% is used for ______?

Answer 27

fluid resuscitation, fluid mobilization

Question 28

What is not recommended for resuscitation in septic shock?

Answer 28

starches

Question 29

Explain the results of the SAFE and ALBIOS trials?

Answer 29

No difference in days spent in ICU when comparing 4% albumin to normal saline in sepsis treatment…don’t use albumin upfront

Question 30

What is the first-line vasopressor for septic shock?

Answer 30

norepinephrine

Question 31

What is the second-line vasopressor for septic shock?

Answer 31

vasopressin (if MAP still <65 mmHg)

Question 32

When is dobutamine a good option for septic shock?

Answer 32

presenting with cardiogenic shock symptoms as well

Question 33

Which medications are not recommended in septic shock? (2)

Answer 33

angiotensin II, phenylephrine

Question 34

Which steroids are added on to help with refractory shock?

Answer 34

hydrocortisone, fludrocortisone (more mineralocorticoid activity)

Question 35

When are steroids added on to help in septic shock?

Answer 35

when it is considered refractory and there is an ongoing need for vasopressors