Exam 3 lecture 6

Question 1

What are two major diabetic emergenices

Answer 1

DKA and HHS

Question 2

mortality of DKA vs HHS

Answer 2

DKA<1%
HHS 5-16%

Question 3

Type 1 DM leads to
a) DKA
b)HHS

Answer 3

DKA

Question 4

type 2 DM leads to
A)DKA
B)HHS

Answer 4

HHS

Question 5

what are some counter regulatory hormones that increase hyperglycemia

Answer 5

cortisol, GH, glucagon

Question 6

How does ketoacidosis happen?

Answer 6

no insulin= no glucose for energy. The fuel comes from lipolysis. FFA can not be converted to fuel and gets shifted into ketogenic pathway and we get ketones, leading to ketoacidosis.

Question 7

symptoms in HHS

Answer 7

we have a profound glucosuria that dehydrates Pt

Question 8

leading percipitating factor in DKA

Answer 8

infection

Question 9

DKA pt symptoms

Answer 9

N/V abdomen pain
Kussmaul breathing

Question 10

anion gap for mild dka? moderate/severe?

Answer 10

> 10
severe moderate >12

Question 11

urine or blood b-hydroxybutyrate in DKA

Answer 11

> 3

Question 12

other signs of DKA

Answer 12

positive urine blood acetoacetate

Question 13

what is the DKA triad

Answer 13

Hyperglycemia, hyperketonemia, metabolic acidosis

Question 14

DKA treatment fluids

Answer 14

Administer 0.9 NS bolus 1 ML bolus in first 1 hour and also 0.5-1 L/hr 0.9 NS

evaluate corrected Na at 2-4 hrs

corrected Na normal/high- change to 1/2 NS and reduce rate by 50%
corrected Na low- continue NS and reduce rate by 50%

when BG approaches 200, change to D5W with 0.45 NS at 150-200 ml/hr with insulin until resolution

Question 15

DKA treatment do questions

Answer 15

..

Question 16

When to start insulin with DKA

Answer 16

started soon after starting fluids

Question 17

DKA treatment insulin

Answer 17

Start with bolus of 0.1 units/kg and start insulin at a rate of 0.1 units/kg/hour

when blood plasma reaches 200 reduce insulin infusion rate to 0.02-0.05 units/kg/hr

change fluids from NS to 1/2 NS and D5W and at 150-250 ml/hr

adjust insulin and D5W to maintain glucose 150-200

Question 18

when to transition to subQ insulin from IV in DKA pts

Answer 18

BG<200
AND atleast 2 of the following below
- anion gap closes < or = 12
- Bicarbonate lvl > or = 13
- venous PH >7.2

Question 19

dosing regimens for transitioning from Dub1 to IV

Answer 19

restart home regimen if successful
OR
add subq rapid insulin Q 2 hours at 0.1 units/kg
OR
Insulin naive patients (new pts) start multidose regimen of 0.5-0.8 units/kg/day divided 50/50 basal bolus
OR
Add up total amount of IV insulin required by patient, convert to estimated daily requirement using basal/bolus or NPH q 6h

Question 20

what is something we should ALWAYS do when transitioning from IV to subq

Answer 20

Overlap IV and subq by 2-4 hours to prevent rebound ketoacidosis or hyperglycemia

Question 21

Anion gap formula

Answer 21

Na-(Cl+bicarb)

Question 22

anion gap of 12 or above is called

Answer 22

metabolic acidosis

Question 23

What happens to K in ketoacidosis? What are the normal levels of K? Acidosis level of K?

Answer 23

K becomes extracellular
Normal PH- K is 3.5-5
acidosis- K is 5+

Question 24

When should we never start Insulin

Answer 24

K<3.3

Question 25

K levels in DKA and what to do in each case

Answer 25

K>5- no supplementation needed K 4-5 Add 20 meq KCl per liter K 3-4 Add 40 Meq Kcl K<3 Add 10-20 meq/hr until k>3, then supplement 40 meq

Question 26

What happens to Na in DKA? why?

Answer 26

Na<135 in DKA This is because intracellular fluid is moving to extracellular space, diluting Na, so it seems low. That is why we calculate the CF

Question 27

When to give bicarb and when to give phosphate?

Answer 27

Give 500-100 mmol bicarb when PH<6.9 phosphate <1 supplement

Question 28

What is euglycemic DKA

Answer 28

patient presents with normal or slightly elevated glucose and urine is positive for ketones.

Question 29

symptoms of DKA? More likely in T1 or T2?

Answer 29

N/V abdominal cramps More likley in T-1 DM/ also possible for T2

Question 30

What are we looking for in diagnosing DKA

Answer 30

Ketones in urine and B hydroxybutyrine (low bicarb, low PH, elevated K, low Na)

Question 31

Pt presents with N/V abdominal and positive B hydrocybutyrine 88kg pt K 6.9

Answer 31

most likely DKA, NS bolus 1 L and NS 500-1000 mL insulin- 0.1x88 kg- 9 units bolus 0.1 x 88 = 9 units/hr infusion (K is >3.3 so we can start insulin)

Question 32

repeat lab shows BG 350, Na 131, K 4.8 how would you adjust fluid, electrolyte and insulin?

Answer 32

Calculate corrected Na= 135= normal 1/2 the rate and convert to 1/2 NS K is low, add 20 Meq, no D5W can be added because BG is not 200 yet, no SQ for this reason even though Anion gap is low and bicarb is sufficient

Question 33

pathogenesis of HHS

Answer 33

Massive glucosuria increased waterloss/ dehydration

Question 34

why doesnt the body produce ketones in HHS

Answer 34

We have some insulin to prevent shift into ketogenesis

Question 35

symptoms of HHS

Answer 35

NO nausea and vomiting and abdominal pain polys and BG is 800-2400 (BUN>100)

Question 36

serum osmolarity in HHS

Answer 36

>320

Question 37

hhs goals of tx

Answer 37

Restore circulatory volume (fluid) restore urine output to 50 ml/h (fluids) return BG to normal (fluids+insulin)

Question 38

how to treat HHS (fluids)

Answer 38

administer 0.45% or 0.9% NS as 0.5-1L for 1-4 hours evaluate corrected Na If normal/high- reduce rate If low- consider NS When BS is 300, change to D5W with 0.45% NS at 150-250 mL/hr until resolution

Question 39

Difference in tx between DKA and HHS

Answer 39

In HHS, administer 0.45% or 0.9% NS at 0.5-1 L, no 0.45% NS in DKA Goal to change to D5W with 0.45 % NS is 300 in HHS, it is 200 in DKA

Question 40

How to treat HHS (insulin)

Answer 40

similar to DKA Start at 0.1 units/kg/hr with bolus of 0.1 units/kg check glucose every hour decrease infusion to 0.02-0.05 units/kg/hr and maintain a glucose of 200-300 units (in DKA goal was 150-200) when mentally alert transition to sq

Question 41

PM is a 63 YOM with Na-136 Cl 104 K 3.6 BUN 94 Scr 1.4 ketones- minimal HCO3- 24 Glucose- 775 PH 7.3 Treat PM

Answer 41

Glucose levels, BUN and no ketones indicate HHS Calculate serum osmolarity to check (HHS if greater than 320) 1/2 NS at 0.5-1 L for 1st for 1-4 hrs Give insulin at 0.1 units/kg/hr with 0.1 units/kg bolus when glucose <300, switch to D5W and reduce rate Decrease infusion rate of insulin to 0.02-0.05 units/kg/hr

Question 42

What are some possible compications when treating DKA and HHS

Answer 42

Cerebral edema if we hydrate too fast