Exam 3 lecture 6 Flashcards
What are two major diabetic emergenices
DKA and HHS
mortality of DKA vs HHS
DKA<1%
HHS 5-16%
Type 1 DM leads to
a) DKA
b)HHS
DKA
type 2 DM leads to
A)DKA
B)HHS
HHS
what are some counter regulatory hormones that increase hyperglycemia
cortisol, GH, glucagon
How does ketoacidosis happen?
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.
symptoms in HHS
we have a profound glucosuria that dehydrates Pt
leading percipitating factor in DKA
infection
DKA pt symptoms
N/V abdomen pain
Kussmaul breathing
anion gap for mild dka? moderate/severe?
> 10
severe moderate >12
urine or blood b-hydroxybutyrate in DKA
> 3
other signs of DKA
positive urine blood acetoacetate
what is the DKA triad
Hyperglycemia, hyperketonemia, metabolic acidosis
DKA treatment fluids
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
DKA treatment do questions
..
When to start insulin with DKA
started soon after starting fluids
DKA treatment insulin
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
when to transition to subQ insulin from IV in DKA pts
BG<200
AND atleast 2 of the following below
- anion gap closes < or = 12
- Bicarbonate lvl > or = 13
- venous PH >7.2
dosing regimens for transitioning from Dub1 to IV
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
what is something we should ALWAYS do when transitioning from IV to subq
Overlap IV and subq by 2-4 hours to prevent rebound ketoacidosis or hyperglycemia
Anion gap formula
Na-(Cl+bicarb)
anion gap of 12 or above is called
metabolic acidosis
What happens to K in ketoacidosis? What are the normal levels of K? Acidosis level of K?
K becomes extracellular
Normal PH- K is 3.5-5
acidosis- K is 5+
When should we never start Insulin
K<3.3
K levels in DKA and what to do in each case
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
What happens to Na in DKA? why?
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
When to give bicarb and when to give phosphate?
Give 500-100 mmol bicarb when PH<6.9
phosphate <1 supplement
What is euglycemic DKA
patient presents with normal or slightly elevated glucose and urine is positive for ketones.
symptoms of DKA? More likely in T1 or T2?
N/V abdominal cramps
More likley in T-1 DM/ also possible for T2
What are we looking for in diagnosing DKA
Ketones in urine and B hydroxybutyrine
(low bicarb, low PH, elevated K, low Na)
Pt presents with N/V abdominal and positive B hydrocybutyrine 88kg pt K 6.9
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)
repeat lab shows BG 350, Na 131, K 4.8 how would you adjust fluid, electrolyte and insulin?
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
pathogenesis of HHS
Massive glucosuria
increased waterloss/ dehydration
why doesnt the body produce ketones in HHS
We have some insulin to prevent shift into ketogenesis
symptoms of HHS
NO nausea and vomiting and abdominal pain
polys and BG is 800-2400
(BUN>100)
serum osmolarity in HHS
> 320
hhs goals of tx
Restore circulatory volume (fluid)
restore urine output to 50 ml/h (fluids)
return BG to normal (fluids+insulin)
how to treat HHS (fluids)
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
Difference in tx between DKA and HHS
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
How to treat HHS (insulin)
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
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
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
What are some possible compications when treating DKA and HHS
Cerebral edema if we hydrate too fast
