Hypoglycaemia/ Hyperglycemia

Question 1

Triad of DKA/ What 3 states characterises DKA

Answer 1

Hyperglycaemia
Hyperketosis
Metabolic acidosis

Hyperglycaemia with high ketones lead to osmotic diuretics and hypovolemia

Question 2

What is DKA a result of

Answer 2

Insulin resistance leads to break down of TGs into fatty acids and glycerol. Free fatty acids break down lead to Ketones.

Question 3

What are the causes of DKA

Answer 3

Infection
Steroids
Thiaqzide
Sympathomimetics

Question 4

What are the causes of HHS

Answer 4

Insulin deficiency
Infection

Question 5

What characterises HHS

Answer 5

Hyperglycaemia without ketones or very mild.

Question 6

List the symptoms of DKA and HHS

Answer 6

Polyuria, polydipsia
Nausea, vomiting
Loss of skin turgor and dry mucous membranes
Altered mental status
Tachycardia, hypotension
Abdominal pain

Question 7

How would you diagnose DKA

Answer 7

(Triad of DKA: hyperglycaemia, hyperketosis &metabolic acidosis)

Blood glucose >250
Urine and serum ketones +
PH<7.3
Anion gap> 12 (Na-(Cl+NaCO3))

Question 8

How would you diagnose HHS

Answer 8

Blood glucose>600
PH>7.3 (DKA is the opposite)
Osmolality >320
Anion gap<12 (there is no anion gap S compared to DKA)
May have trace urine and serum ketones

Question 9

Where would you find leukocytes in urine between DKA and HHS and what does it indicate

Answer 9

Both,
Indicated infection (WCC>25000 with >10% bands)

Question 10

Hyponatremia

Answer 10

False elevated
Water leaves cells into the blood due to increased osmolality in the blood from hyperglycaemia. This then dilutes the Na

Add 1.6 Na for every 100mg/dl glucose
(If glucose >100)

Question 11

What is Hypertryglyceridemia a result of

Answer 11

DKA
Bile tries to find other causes of energy. Influx of triglycerides into blood lowers Na and glucose

Question 12

What investigations would you order for a person presenting with altered mental status/ very septic or sick

Answer 12

ABG, Chem10(anion gap), CBC w/differential (leukocytosis), UA(infection), EKG

CXR and culture looking for precipitating factors of their condition

Determine tx: insulin regimen, IV fluids, Electrolyte Replacement, Need for HCO3

Question 13

How would you manage someone who is hypovolemic

Answer 13

0.9 saline
1l/hour

Question 14

How would you initiate the insulin regimen to a patient presenting with DKA

Answer 14

Start an insulin drip
Starting dose is 0.1 u/kg/hour
Blood glucose should drop by 50-70 mg/dl for first hour

When the payout is able to eat initial a multi dose insulin regimen (long and short acting)

Keys to transitioning to sq insulin
Anion gap should be <12
Blood glucose <200
PH>7.2 (in DKA)

When transitioning to sq insulin keep insulin drip on for 4 hours before stopping

Question 15

How would you manage hypokalemia or hyperkalemia in DKA/HHS

Answer 15

If K<3.3 hold insulin and replace K to >3.3
If K<3.3 but>5 place 20 meq of K of each litre of fluid
If K>5 do not give it but check in 2 hours

Insulin causes hypokalemia as it drives potassium into the cells.
Low Mg also makes it difficult to correct potassium levels

Question 16

When do you give bicarbonate in DKA/HHS

Answer 16

Never give bicarbonate for low bicarbonate level
IV bicarbonate causes cerebral oedema
Only give bicarbonate if pH<7