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PHRM 844 Therapeutics > Exam 3 - Diabetic Emergencies Dr. Brown > Flashcards

Exam 3 - Diabetic Emergencies Dr. Brown Flashcards

1
Q

anion gap formula

A

Na - (Chloride + Bicarb)

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2
Q

3 characteristics of hyperglycemic hyperosmolar state (HHS; slide 4)

A

-severe hyperglycemia
-hyperosmolality
-severe fluid depletion

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3
Q

mortality of DKA and HHS

A

DKA: < 1%
HHS: 5-16%

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4
Q

pathophysiology of DKA and HHS

A

reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone)

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5
Q

DKA usually occurs in

a. T1DM
b. new-onset T2DM
c. both a and b

A

c. both a and b

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6
Q

leading precipitating factor for DKA

A

infection

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7
Q

what causes fruity breath in DKA?

A

acetone

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8
Q

what symptoms occur in 40-75% of DKA pts?

A

-abdominal pain
-N/V

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9
Q

lab value for glucose in DKA

A

> 250 mg/dL

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10
Q

mild DKA blood pH range

A

7.25-7.3

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11
Q

moderate DKA blood pH range

A

7-7.24

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12
Q

severe DKA blood pH

A

< 7

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13
Q

bicarbonate range in mild, moderate, and severe DKA

A

mild: 15-18
moderate: 10-14
severe: < 10

(bicarb is depleted as pt becomes acidodic)

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14
Q

mild DKA anion gap is > ___

A

> 10

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15
Q

moderate and severe DKA anion gap is > ___

A

> 12

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16
Q

what is the DKA triad?

A

hyperglycemia
hyperketonemia
metabolic acidosis

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17
Q

first step for giving fluids for DKA

A

administer NS at 500-1000 mL/hr for first 1-4 hours; evaluate corrected Na+ at 2-4 hours

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18
Q

when giving fluids for DKA, if corrected Na is normal/high, change from NS to _____ and ___ the rate by 50%

A

1/2NS; decrease

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19
Q

when giving fluids for DKA, what is the next step if corrected Na is low?

A

continue NS and dec rate by 50%

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20
Q

fluids and DKA: when blood glucose approaches _____ mg/dL, change to D5W with 0.45% NS @ ___-___ mL/hr until resolution of ketoacidosis

A

200 mg/dL
150-250 mL/hr

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21
Q

what is the second step in management of DKA after fluids are initiated?

A

give insulin

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22
Q

DKA: IV insulin starting dose

A

0.1 units/kg/hr +/- a bolus of 0.1 units/kg

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23
Q

which is most commonly used insulin for DKA?

a. IV
b. subQ
c. IM

A

a. IV

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24
Q

IV insulin for DKA: if glucose does not fall by at least 10% (or 50-70 mg/dL) in the first hour, what should you do?

A

give, repeat, or increase bolus dose (0.1-0.14 units/kg)

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25
Q

IV insulin for DKA: when plasma glucose reaches 200 mg/dL, dec infusion rate to 0.02-0.05 units/kg/hr. What other changes would you make? (2 of them; slide 21)

A

-change fluids from NS to 1/2NS and D5W and dec rate to 150-250 mL/hr
-adjust rate of insulin or rate of dextrose admin to maintain plasma glucose level of 150-200

26
Q

transition from IV insulin to subQ when BG level < 200 mg/dL AND at least 2 of 3 criteria are met? What are the 3 criteria?

A

anion gap closes < or = to 12
bicarb level > or = to 15
venous pH > 7.3

(pt should also not be NPO)

27
Q

true or false: when transitioning from IV to subq insulin, you can restart home regimen if it was working previously

A

true

28
Q

transitioning from IV to subQ insulin for insulin-naive pt: what is the regimen?

A

0.5-0.8 units/kg/day, divided 50/50 basal/bolus

29
Q

insulin-naive pt transitioning from IV to subQ insulin: if they are on 32 units and eat 4 times a day, how would you split up the insulin dose?

A

16 units basal + 4 units with each meal

(50/50 basal/bolus = 16 units basal and 16 units bolus)

30
Q

transitioning from IV to subQ insulin: you can consider adding up total amount of IV insulin required by pt and convert to estimated daily requirement using basal/bolus or every ___ hour ___ insulin

A

6
NPH

31
Q

overlap IV and subQ insulin by how many hours?

A

2-4

(to prevent rebound ketoacidosis or hyperglycemia)

32
Q

an anion gap of > or = to ___ suggests metabolic acidosis

A

12

33
Q

when anion gap “closes” or becomes < ___, we can begin to think about transitioning from IV to subQ insulin

A

12

34
Q

electrolytes of concern for DKA (4 of them)

A

potassium, sodium, phosphate, anion gap

35
Q

as fluids are started for DKA, maintain a potassium conc of ___-___ mmol/L

A

4-5

36
Q

DKA and potassium: as fluids are started, do NOT start insulin if K < ___ mmol/L

A

3.3

37
Q

DKA and potassium: if K > 5, what supplementation is needed?

A

none needed

38
Q

DKA and potassium: if K is 4-5, add ___ mEq KCl per L to replacement fluids

A

20

39
Q

DKA and potassium: if K is 3-4, add ___ mEq KCl per L to replacement fluids

A

40

40
Q

DKA and potassium: if K is < 3, add ___-___ mEq KCl until K > ___, then supplement ___ mEq

A

10-20 mEq
3
40 mEq

41
Q

true or false: phosphate conc increases with insulin therapy

A

false

42
Q

DKA and bicarb: if pH is < 6.9, then

a. no bicarb needed
b. give 50-100 mmol bicarb q1-2 h until pH > or = to 7
c. give 50-100 mmol bicarb q3-4 h until pH > or = to 7

A

b. give 50-100 mmol bicarb q1-2 h until pH > or = to 7

43
Q

DKA and bicarb: if pH > or = to 6.9, then

a. no bicarb needed
b. give 50-100 mmol bicarb q1-2 h until pH > or = to 7
c. give 50-100 mmol bicarb q3-4 h until pH > or = to 7

A

a. no bicarb needed

44
Q

what is euglycemic DKA?

A

when pts have normal BG levels, but urine is still positive for ketones

(SGLT2 inhibitors can cause this)

45
Q

euglycemic DKA may require more _____ earlier in therapy but treatment is generally similar to other forms of DKA

A

dextrose

46
Q

hyperglycemic hyperosmolar state (HHS) generally occurs in ____ pts

a. younger
b. older

A

b. older

47
Q

true or false: ketones are usually present in urine in HHS

A

false

(ketones are absent or very low)

48
Q

serum osmolality > ___ for HHS

A

320 mOsm/kg

49
Q

BUN > ___ for HHS

A

100 mg/dL

50
Q

fluids for HHS: administer ___ or ___ at ___-___ mL/hr for first ___-___ hours

A

1/2NS
NS
500-1000 mL/hr
1-4 hours

51
Q

fluids for HHS: if corrected Na is normal/high, _____ the rate

A

reduce

52
Q

fluids for HHS: if corrected Na is low, consider ___

A

NS

53
Q

fluids for HHS: when BS is ___ mg/dL, change to D5W w/ 1/2NS @ 150-250 mL/hr util resolution of HHS

A

300 mg/dL

54
Q

IV insulin dose for HHS

A

start 0.1 units/kg/hr +/- bolus of 0.1 units/kg

55
Q

IV insulin for HHS: once at 300 mg/dL, dec infusion to ___-___units/kg/hr and maintain a glucose of ___-___ mg/dL until pt is mentally alert

A

0.02-0.05 units/kg/hr
200-300 mg/dL

56
Q

when do we transition from IV insulin to subQ in HHS?

A

when pt is mentally alert

57
Q

DKA and HHS complications: cerebral edema -> what is the treatment? (2 things)

A

mannitol + mechanical ventilation

58
Q

how to avoid cerebral edema in DKA and HHS?

A

do not hydrate too fast

59
Q

DKA and HHS complications: hypoglycemia -> caused by too much _____

A

insulin

60
Q

DKA and HHS complications: hypoglycemia -> what is the treatment?

A

reduce insulin, give glucose (either D50 IV push, or oral glucose if pt is alert enough), consider glucagon

PHRM 844 Therapeutics (28 decks)

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