Exam 3 - Diabetic Emergencies Dr. Brown

Question 1

anion gap formula

Answer 1

Na - (Chloride + Bicarb)

Question 2

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

Answer 2

-severe hyperglycemia
-hyperosmolality
-severe fluid depletion

Question 3

mortality of DKA and HHS

Answer 3

DKA: < 1%
HHS: 5-16%

Question 4

pathophysiology of DKA and HHS

Answer 4

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

Question 5

DKA usually occurs in

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

Answer 5

c. both a and b

Question 6

leading precipitating factor for DKA

Answer 6

infection

Question 7

what causes fruity breath in DKA?

Answer 7

acetone

Question 8

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

Answer 8

-abdominal pain
-N/V

Question 9

lab value for glucose in DKA

Answer 9

> 250 mg/dL

Question 10

mild DKA blood pH range

Answer 10

7.25-7.3

Question 11

moderate DKA blood pH range

Answer 11

7-7.24

Question 12

severe DKA blood pH

Answer 12

< 7

Question 13

bicarbonate range in mild, moderate, and severe DKA

Answer 13

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

(bicarb is depleted as pt becomes acidodic)

Question 14

mild DKA anion gap is > ___

Answer 14

> 10

Question 15

moderate and severe DKA anion gap is > ___

Answer 15

> 12

Question 16

what is the DKA triad?

Answer 16

hyperglycemia
hyperketonemia
metabolic acidosis

Question 17

first step for giving fluids for DKA

Answer 17

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

Question 18

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

Answer 18

1/2NS; decrease

Question 19

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

Answer 19

continue NS and dec rate by 50%

Question 20

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

Answer 20

200 mg/dL
150-250 mL/hr

Question 21

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

Answer 21

give insulin

Question 22

DKA: IV insulin starting dose

Answer 22

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

Question 23

which is most commonly used insulin for DKA?

a. IV
b. subQ
c. IM

Answer 23

a. IV

Question 24

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?

Answer 24

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

Question 25

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)

Answer 25

-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

Question 26

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?

Answer 26

anion gap closes < or = to 12 bicarb level > or = to 15 venous pH > 7.3 (pt should also not be NPO)

Question 27

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

Answer 27

true

Question 28

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

Answer 28

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

Question 29

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?

Answer 29

16 units basal + 4 units with each meal (50/50 basal/bolus = 16 units basal and 16 units bolus)

Question 30

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

Answer 30

6 NPH

Question 31

overlap IV and subQ insulin by how many hours?

Answer 31

2-4 (to prevent rebound ketoacidosis or hyperglycemia)

Question 32

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

Answer 32

12

Question 33

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

Answer 33

12

Question 34

electrolytes of concern for DKA (4 of them)

Answer 34

potassium, sodium, phosphate, anion gap

Question 35

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

Answer 35

4-5

Question 36

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

Answer 36

3.3

Question 37

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

Answer 37

none needed

Question 38

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

Answer 38

20

Question 39

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

Answer 39

40

Question 40

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

Answer 40

10-20 mEq 3 40 mEq

Question 41

true or false: phosphate conc increases with insulin therapy

Answer 41

false

Question 42

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

Answer 42

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

Question 43

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

Answer 43

a. no bicarb needed

Question 44

what is euglycemic DKA?

Answer 44

when pts have normal BG levels, but urine is still positive for ketones (SGLT2 inhibitors can cause this)

Question 45

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

Answer 45

dextrose

Question 46

hyperglycemic hyperosmolar state (HHS) generally occurs in ____ pts a. younger b. older

Answer 46

b. older

Question 47

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

Answer 47

false (ketones are absent or very low)

Question 48

serum osmolality > ___ for HHS

Answer 48

320 mOsm/kg

Question 49

BUN > ___ for HHS

Answer 49

100 mg/dL

Question 50

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

Answer 50

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

Question 51

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

Answer 51

reduce

Question 52

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

Answer 52

NS

Question 53

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

Answer 53

300 mg/dL

Question 54

IV insulin dose for HHS

Answer 54

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

Question 55

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

Answer 55

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

Question 56

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

Answer 56

when pt is mentally alert

Question 57

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

Answer 57

mannitol + mechanical ventilation

Question 58

how to avoid cerebral edema in DKA and HHS?

Answer 58

do not hydrate too fast

Question 59

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

Answer 59

insulin

Question 60

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

Answer 60

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