Hyperglycemic Crises: DKA and HHS

Question 1

DKA

Answer 1

potentially life threatening condition that results from the absolute or relative deficiency in insulin

Question 2

3 characteristics of DKA

Answer 2

1. ketosis
2. metabolic acidosis
3. hyperglycemia

Question 3

DKA etiology

Answer 3

infection, surgery, trauma
undiagnosed T1DM
changes in diabetic management
life changes which increase insulin demand (pregnancy and puberty)
acute pancreatitis
starvation
increased alcohol intake
medications (Steroids)
unknown

Question 4

DKA acidosis pathophysiology

Answer 4

absence of insulin prevents uptake of glucose into cells -> glucose/energy needs unmet -> lipolysis via oxidation process for energy -> FFA production for energy -> acidosis

Question 5

DKA hyperglycemia patho

Answer 5

absence of insulin prevents uptake of glucose into cells -> glucose/energy needs unmet -> liver is stimulated to increase glucose production through glycogenolysis and gluconeogenesis -> worsens hyperglycemia

Question 6

DKA ketosis patho

Answer 6

KETOSIS: FFA production -> FFAs travel to liver -> FFAs activated by coenzyme A -> forms acetyl-CoA -> converted to ketones for energy -> ketosis

Question 7

DKA compensation methods/patho

Answer 7

circulating ketones increase, decreasing pH and causes metabolic acidosis
respiratory center stimulated to blow off CO2
kidneys attempt to conserve bicarb for buffering
potassium

Question 8

DKA osmotic diuresis patho

Answer 8

elevated glucose increases intravascular osmotic pressure -> fluids move to intravascular space -> kidneys respond to increased volume with large volume diuresis (of water, glucose, lytes)
hyponatremia and hypotension activate RAAS

Question 9

DKA patho overview

Answer 9

process of catabolizing fats for fuel leads to development of
1. ketosis and acidosis
2. dehydration
3. electrolyte imbalance
gluconeogenesis/glycogenesis leads to
4. hyperglycemia

Question 10

DKA s/s

Answer 10

glucose >250, <600
arterial pH <7.3
serum bicarb </= 18
moderate ketonemia or ketonuria

Question 11

DKA manifestations

Answer 11

polydipsia, polyphagia, polyuria
dehydration, dry mouth
tachycardia
changes in LOC (mild disorientation, confusion)
respiratory (air hunger, acetone breath, increased RR)
N/V

Question 12

mild DKA definition

Answer 12

pH 7.25-7.3
serum bicarb 15-18
anion gap >10o

Question 13

moderate DKA definition

Answer 13

pH 7-7.24
serum bicarb 10-14
anion gap >12

Question 14

severe DKA definition

Answer 14

pH < 7
bicarb < 10
anion gap >12

Question 15

DKA dehydration management

Answer 15

1L NS
then D51/2NS

Question 16

DKA hypokalemia management

Answer 16

K<3.3 = IVF w/K
K 3.3-5.2 = IVF w/K and insulin drip
K >5.2 = IVF with no K, insulin drip
check K levels q2hrs while on insulin drip

Question 17

DKA hyperglycemia management

Answer 17

regular insulin drip
hourly glucose monitoring

Question 18

DKA acidosis management

Answer 18

IV NaHCO3

Question 19

what does potassium do during DKA tx

Answer 19

shifts back into cell as acidotic state is corrected
and with admin of insulin

Question 20

what does sodium do during DKA tx

Answer 20

initiation of rehydration phase can shift sodium rapidly

Question 21

what does phosphate do during DKA tx

Answer 21

may become depleted during acidosis because it is a buffer

Question 22

DKA NANDA

Answer 22

deficient fluid volume
electrolyte imbalance

Question 23

HHS

Answer 23

hyperglycemic complication of diabetes mellitus that results from insulin deficiency and resistance

Question 24

HHS 3 characteristics

Answer 24

1. hyperglycemia without significant ketoacidosis
2. hyperosmolarity
3. dehydration

Question 25

HHS highest risk pts

Answer 25

T2DM
older, obese pts with underlying CV conditions

Question 26

HHS etiology

Answer 26

infection (pneumonia, UTI)
stroke/MI
stress of illness
meds (corticosteroids)

Question 27

HHS patho

Answer 27

insulin available in sufficient amounts to inhibit lipolysis and ketogenesis but insufficient to prevent hyperglycemia
liver is still stimulated to produce glucose for energy
absence of adequate insulin -> additional glucose cannot enter cells -> increasing hyperglycemia
serum osmo increases and water moves intravascularly
osmotic diuresis occurs
glucose concentration increases due to loss of circulating volume

Question 28

HHS s/s

Answer 28

glucose >600
arterial pH<7.3
increased Hct
elevated BUN

Question 29

HHS manifestations

Answer 29

resp rapid and shallow
N/V
electrolyte imbalances
polydipsia
decrease in LOC

Question 30

HHS dehydration management

Answer 30

1L NS
then 1/2NS till BG 250
then D51/2NS

Question 31

HHS hypokalemia management

Answer 31

K<3.3 = IVF w/K
K 3.3-5.2 = IVF w/K and insulin drip
K >5.2 = IVF with no K, insulin drip
check K levels q2hrs while on insulin drip

Question 32

HHS hyperglycemia

Answer 32

insulin drip

Question 33

potential complications of tx

Answer 33

hypokalemia dramatically
fluid overload