Exam 3 - Diabetic Emergencies Dr. Brown Flashcards
anion gap formula
Na - (Chloride + Bicarb)
3 characteristics of hyperglycemic hyperosmolar state (HHS; slide 4)
-severe hyperglycemia
-hyperosmolality
-severe fluid depletion
mortality of DKA and HHS
DKA: < 1%
HHS: 5-16%
pathophysiology of DKA and HHS
reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone)
DKA usually occurs in
a. T1DM
b. new-onset T2DM
c. both a and b
c. both a and b
leading precipitating factor for DKA
infection
what causes fruity breath in DKA?
acetone
what symptoms occur in 40-75% of DKA pts?
-abdominal pain
-N/V
lab value for glucose in DKA
> 250 mg/dL
mild DKA blood pH range
7.25-7.3
moderate DKA blood pH range
7-7.24
severe DKA blood pH
< 7
bicarbonate range in mild, moderate, and severe DKA
mild: 15-18
moderate: 10-14
severe: < 10
(bicarb is depleted as pt becomes acidodic)
mild DKA anion gap is > ___
> 10
moderate and severe DKA anion gap is > ___
> 12
what is the DKA triad?
hyperglycemia
hyperketonemia
metabolic acidosis
first step for giving fluids for DKA
administer NS at 500-1000 mL/hr for first 1-4 hours; evaluate corrected Na+ at 2-4 hours
when giving fluids for DKA, if corrected Na is normal/high, change from NS to _____ and ___ the rate by 50%
1/2NS; decrease
when giving fluids for DKA, what is the next step if corrected Na is low?
continue NS and dec rate by 50%
fluids and DKA: when blood glucose approaches _____ mg/dL, change to D5W with 0.45% NS @ ___-___ mL/hr until resolution of ketoacidosis
200 mg/dL
150-250 mL/hr
what is the second step in management of DKA after fluids are initiated?
give insulin
DKA: IV insulin starting dose
0.1 units/kg/hr +/- a bolus of 0.1 units/kg
which is most commonly used insulin for DKA?
a. IV
b. subQ
c. IM
a. IV
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?
give, repeat, or increase bolus dose (0.1-0.14 units/kg)
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)
-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
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?
anion gap closes < or = to 12
bicarb level > or = to 15
venous pH > 7.3
(pt should also not be NPO)
true or false: when transitioning from IV to subq insulin, you can restart home regimen if it was working previously
true
transitioning from IV to subQ insulin for insulin-naive pt: what is the regimen?
0.5-0.8 units/kg/day, divided 50/50 basal/bolus
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?
16 units basal + 4 units with each meal
(50/50 basal/bolus = 16 units basal and 16 units bolus)
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
6
NPH
overlap IV and subQ insulin by how many hours?
2-4
(to prevent rebound ketoacidosis or hyperglycemia)
an anion gap of > or = to ___ suggests metabolic acidosis
12
when anion gap “closes” or becomes < ___, we can begin to think about transitioning from IV to subQ insulin
12
electrolytes of concern for DKA (4 of them)
potassium, sodium, phosphate, anion gap
as fluids are started for DKA, maintain a potassium conc of ___-___ mmol/L
4-5
DKA and potassium: as fluids are started, do NOT start insulin if K < ___ mmol/L
3.3
DKA and potassium: if K > 5, what supplementation is needed?
none needed
DKA and potassium: if K is 4-5, add ___ mEq KCl per L to replacement fluids
20
DKA and potassium: if K is 3-4, add ___ mEq KCl per L to replacement fluids
40
DKA and potassium: if K is < 3, add ___-___ mEq KCl until K > ___, then supplement ___ mEq
10-20 mEq
3
40 mEq
true or false: phosphate conc increases with insulin therapy
false
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
b. give 50-100 mmol bicarb q1-2 h until pH > or = to 7
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. no bicarb needed
what is euglycemic DKA?
when pts have normal BG levels, but urine is still positive for ketones
(SGLT2 inhibitors can cause this)
euglycemic DKA may require more _____ earlier in therapy but treatment is generally similar to other forms of DKA
dextrose
hyperglycemic hyperosmolar state (HHS) generally occurs in ____ pts
a. younger
b. older
b. older
true or false: ketones are usually present in urine in HHS
false
(ketones are absent or very low)
serum osmolality > ___ for HHS
320 mOsm/kg
BUN > ___ for HHS
100 mg/dL
fluids for HHS: administer ___ or ___ at ___-___ mL/hr for first ___-___ hours
1/2NS
NS
500-1000 mL/hr
1-4 hours
fluids for HHS: if corrected Na is normal/high, _____ the rate
reduce
fluids for HHS: if corrected Na is low, consider ___
NS
fluids for HHS: when BS is ___ mg/dL, change to D5W w/ 1/2NS @ 150-250 mL/hr util resolution of HHS
300 mg/dL
IV insulin dose for HHS
start 0.1 units/kg/hr +/- bolus of 0.1 units/kg
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
0.02-0.05 units/kg/hr
200-300 mg/dL
when do we transition from IV insulin to subQ in HHS?
when pt is mentally alert
DKA and HHS complications: cerebral edema -> what is the treatment? (2 things)
mannitol + mechanical ventilation
how to avoid cerebral edema in DKA and HHS?
do not hydrate too fast
DKA and HHS complications: hypoglycemia -> caused by too much _____
insulin
DKA and HHS complications: hypoglycemia -> what is the treatment?
reduce insulin, give glucose (either D50 IV push, or oral glucose if pt is alert enough), consider glucagon
