Hyperglycemia Flashcards
Hyperglycemia is defined as:
Fasting Blood Glucose (for 8 hrs) > 90 – 130 mg/dL
Postprandial Blood Glucose > 180 mg/dL
What is DKA and what are common triggers?
Is a state of absolute insulin deficiency, hyperglycemia, anion gap acidosis, and dehydration.
infections, disruption of insulin therapy, or as the presentation of new onset diabetes.
Type I
What is hyperosmolar hyperglycemic state?
hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis.
Higher mortality rate
Type II
In hemodynamically unstable and those suspected of having DKA or HHS the following should be instituted;
Close attention should be paid to the ABC’s
2 large bore intravenous lines should be placed
Normal saline 1-2 liters (adult), bolus of 20 cc/kg (children), attention should be paid to the volume status of the patient. Be cautious of high volume crystalloid infusion in patients with congestive heart failure or chronic renal failure
Place the patient on a cardiac monitor
What glucose level do patients start to develop an osmotic diuresis?
>180 May then have symptoms: - Polyuria - Polydipsia - Polyphagia - Weight loss
Physical exam findings in patients with hyperglycemia
tachycardia, dizziness, lightheadedness and weakness as a result of dehydration and electrolyte imbalance.
DKA symptoms
Abdominal pain
Hyperpneic respirations (fast and deep Kaussmaul respirations)
Hypotension
Ketotic breath (fruity odor in DKA)
Marked tachycardia
Neurologic symptoms (seizures, focal weakness, lethargy, coma, death) – more prevalent in HHS
DKA diagnostic criteria
Plasma glucose >250 Arterial pH < 7.30 Serum bicarb < 18 Urine ketones +++ Serum Ketones +++ Serum Osmolality Increased Anion gap >>>12 Mental status Variable (from alert to coma)
Hyperosmolar hyperglycemic state
Plasma glucose >600 Arterial pH > 7.30 Serum bicarb > 18 Urine ketones negative or faintly positive Serum Ketones negative or faintly positive Serum Osmolality Very Increased Anion gap Normal 12-16 Mental status Stupor/Coma
Goals of treatment
Treatment for DKA and HHS is centered around correcting the intravascular volume depletion, management of electrolyte abnormalities, insulin replacement therapy and identification of and treatment of any underlying precipitants.
Fluid Therapy.
- Average fluid loss in DKA 3-6 liters and HHS 8-10 liters
- Start with isotonic saline (0.9%) at 15-20 ml/kg per hour for the first few hours (in the average adult this will be approximately 1 liter/hr)
- Switch to one-half isotonic saline (0.45%) when the serum sodium normalizes
- Add dextrose to the intravenous fluids when serum glucose reaches 250 mg/dL
Insulin therapy
- Insulin therapy should only be started after adequate fluid resuscitation
- Start with an infusion of regular insulin at 0.1 U/kg/hr
- Double the dose of insulin if the blood glucose does not fall by 50-70 mg/dL in the first hour
Potassium Replacement
If the initial potassium is < 3.3 mEq/L then DELAY insulin therapy until fluid and potassium replacement
Administer potassium with initial fluid replacement if potassium levels are normal or low and maintained between 4 – 5 mEq/L
What few situations warrant bicarbonate
Severe acidosis with pH < 6.90
Severe life-threatening hyperkalemia
Seizures
Cardiac or persistently hypotensive patient
What is the most serious complication of DKA/HHS?
Cerebral edema
Mainly seen in children and young adults, occurring 4-12 hours into treatment with a high degree of morbidity and mortality. Clinically it is often preceded by headache, lethargy, and then neurologic deterioration (seizures, coma) with bradycardia and respiratory arrest.
