Hyperglycaemia

Question 1

Do glucose levels need to be increased to have DKA?

Answer 1

No, you can have euglycemic ketoacidosis

Question 2

Common conditions that trigger/precipitate DKA/HHS[6]

Answer 2

Infarction/vascular: Stroke, Acute coronary syndrome, GI tract and PVD
Infections: Respiratory or UTIs
Pancreatitis
New diabetes

Question 3

State two pathognomonic features of DKA.

Answer 3

Kussmaul breathing and fruity breath

Question 4

Causes of high anion gap metabolic acidosis[8]

Answer 4

Methanol
Uremia
DKA, Alcoholic ketoacidosis and starvation ketoacidosis
Paracetamol, phenformin and paraldehyde
Iron. Isoniazid, inborn errors of metabolism
Lactic acidosis
Ethanol, ethylene glycol
Salicylate/ASA/aspirin toxicity

These can be used as differentials for DKA

Question 5

Name two GI conditions that mimics DKA/HHS

Answer 5

Acute pancreatitis and acute appendicitis

Question 6

Do hypophosphatemia and hypothermia mimic DKA?

Answer 6

Yes

Question 7

When should IV NaCl be changed to dextrose 5% in the management of HHS/DKA?

Answer 7

When glucose drops by 15 mmol/l

Question 8

What should be done in HHS if serum osmolality and glucose are not decreasing despite giving IV normal saline?

Answer 8

Give IV 0.45% NaCl

Question 9

When should potassium be given in the management of DKA/HHS?

Answer 9

When serum potassium<5 mmol/l

20mmol in each litre of fluid if K+ 4.1 – 5 mmol/L
30mmol in each litre of fluid if K+ = 3.1 – 4 mmol/L
40mmol in each litre of fluid if K+ < 3.1 mmol/L

Question 11

List components of the supportive care during management of DKA/HHS?

Answer 11

Monitor urine output
Drowsy/decrease level of consciousness: give DVT prophylaxis
Organise ICU, HDU or acute medical admission

Question 12

What can be done if the patient with DKA has a pH below 7 and are now stable?

Answer 12

Bicarbonate however they have been shown to worsen ketosis
Empiric antibiotics

Question 13

What should be considered to decrease risk of gastric dilation and aspiration during acute management of DKA/HHS?

Answer 13

Nasogastric tube

Question 15

State how you determine resolution of DKA/HHS?

Answer 15

Glucose < 11mmol/L
Bicarbonate >/= to 18
pH > 7.3
Anion gap < 12
Normal level of consciousness
Patient able to eat and drink

However: Further inpatient glucose monitoring should be done.

Question 16

Should newly diagnosed diabetes who presented with DKA be started on insulin?

Answer 16

Yes, insulin sliding scale

Question 17

Investigations that should be done in all patients presenting with DKA/HHS?

Answer 17

Blood glucose, urea and electrolytes(sodium, potassium) and creatinine and determine serum osmolality
Venous blood gas: Determine metabolic acidosis and anion gap
Start looking for a cause
1. FBC
2. Chest X-ray: looking for pneumonia or signs of infection
3. Urinalysis: looking for infection(UTI)
4. EKG w or w/t ECHO: Looking for Acute coronary syndrome and hypo/Hyperkalemia
5. Sepsis: Blood cultures, throat/wounds swabs and urine/sputum microscopy with culture.

Question 18

Who should be discharged if they came in with DKA/HHS?

Answer 18

No one

They all need to be referred