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Therapeutics P2 > Exam 3 lecture 6 > Flashcards

Exam 3 lecture 6 Flashcards

1
Q

What are two major diabetic emergenices

A

DKA and HHS

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2
Q

mortality of DKA vs HHS

A

DKA<1%
HHS 5-16%

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3
Q

Type 1 DM leads to
a) DKA
b)HHS

A

DKA

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4
Q

type 2 DM leads to
A)DKA
B)HHS

A

HHS

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5
Q

what are some counter regulatory hormones that increase hyperglycemia

A

cortisol, GH, glucagon

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6
Q

How does ketoacidosis happen?

A

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.

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7
Q

symptoms in HHS

A

we have a profound glucosuria that dehydrates Pt

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8
Q

leading percipitating factor in DKA

A

infection

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9
Q

DKA pt symptoms

A

N/V abdomen pain
Kussmaul breathing

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10
Q

anion gap for mild dka? moderate/severe?

A

> 10
severe moderate >12

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11
Q

urine or blood b-hydroxybutyrate in DKA

A

> 3

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12
Q

other signs of DKA

A

positive urine blood acetoacetate

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13
Q

what is the DKA triad

A

Hyperglycemia, hyperketonemia, metabolic acidosis

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14
Q

DKA treatment fluids

A

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

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15
Q

DKA treatment do questions

A

..

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16
Q

When to start insulin with DKA

A

started soon after starting fluids

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17
Q

DKA treatment insulin

A

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

18
Q

when to transition to subQ insulin from IV in DKA pts

A

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

19
Q

dosing regimens for transitioning from Dub1 to IV

A

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

20
Q

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

A

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

21
Q

Anion gap formula

A

Na-(Cl+bicarb)

22
Q

anion gap of 12 or above is called

A

metabolic acidosis

23
Q

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

A

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

24
Q

When should we never start Insulin

A

K<3.3

25
Q

K levels in DKA and what to do in each case

A

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

26
Q

What happens to Na in DKA? why?

A

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

27
Q

When to give bicarb and when to give phosphate?

A

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

28
Q

What is euglycemic DKA

A

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

29
Q

symptoms of DKA? More likely in T1 or T2?

A

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

30
Q

What are we looking for in diagnosing DKA

A

Ketones in urine and B hydroxybutyrine

(low bicarb, low PH, elevated K, low Na)

31
Q

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

A

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)

32
Q

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

A

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

33
Q

pathogenesis of HHS

A

Massive glucosuria
increased waterloss/ dehydration

34
Q

why doesnt the body produce ketones in HHS

A

We have some insulin to prevent shift into ketogenesis

35
Q

symptoms of HHS

A

NO nausea and vomiting and abdominal pain
polys and BG is 800-2400

(BUN>100)

36
Q

serum osmolarity in HHS

A

> 320

37
Q

hhs goals of tx

A

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

38
Q

how to treat HHS (fluids)

A

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

39
Q

Difference in tx between DKA and HHS

A

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

40
Q

How to treat HHS (insulin)

A

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

41
Q

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

A

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

42
Q

What are some possible compications when treating DKA and HHS

A

Cerebral edema if we hydrate too fast

Therapeutics P2 (41 decks)

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