Module 5: DKA & HHS

Question 1

anabolic effects of insulin on liver

Answer 1

1. promotes glycogen synthesis 2. promotes fatty acid synthesis

Question 2

anabolic effects of insulin on adipose

Answer 2

1. promote fatty acid uptake 2. promote triglyceride formation & storage

Question 3

anabolic effects of insulin on muscle

Answer 3

1. promote protein synthesis 2. promote glycogen synthesis

Question 4

anticatabolic effects of insulin on liver

Answer 4

inhibits 1. glycogenolysis 2. gluconeogenesis 3. ketogenesis

Question 5

anticatabolic effects of insulin on adipose

Answer 5

inhibits lipolysis

Question 6

anticatabolic effects of insulin on muscle

Answer 6

inhibit proteolysis

Question 7

criteria for DKA

Answer 7

glucose > 250; arterial pH < 7.35; positive serum ketones; increased anion gap (Anion gap = Na+ - (HCO3- + Cl-)

Question 8

criteria for HHS (DM2)

Answer 8

glucose >600; arterial pH > 7.3; serum bicarb > 15; >320 mOsm/L

Question 9

effective osmolarity?

Answer 9

Eosm = 2(Na + K) + Blood glucose/18 don’t use BUN b/c isn’t considered effective OSM b/c doesn’t create an osmotic gradient b/c can flow into /out of cell

Question 10

mixed DKA & HHS?

Answer 10

pH 7.3 or serum bicarb < 15; positive serum ketones; Esom >320

Question 11

different types of ketosis?

Answer 11

diabetic ketoacidosis; starvation ketosis; alcoholic ketoacidosis; ketogenic (high fat) diets

Question 12

symptoms of hyperglycemia?

Answer 12

polyuria; polydipsia; nocturia; polyphasic; weight loss; vomiting; abdominal pain; fatigue; confusion –> coma; blurred vision; vulvovaginitis; poor wound healing; asymptomatic

Question 13

causes of polyuria

Answer 13

hyperglycemia; hypokalemia; hypercalcemia; renal disorders; psychogenic polydipsia; neurogenic/nephrogenic diabetes insipidus; drugs (diuretics, lithium, demeclocycline)

Question 14

precipitating factors for DKA

Answer 14

1. new onset DM1 2. omission of insulin therapy 3. acute illness (UTI, PNA, medication, MI, CVA, trauma, hyperthyroidism, intra-abdominal catastrophe)

Question 15

risk factors for DKA at onset

Answer 15

age < 12; no first degree relative with diabetes; lower SES; high dose glucocorticoids/atypical antipsychotics; poor access to medical care; uninsured

Question 16

why insulin omission

Answer 16

weight control, fear of hypoglycemia, teenage rebellion

Question 17

cocaine use and DKA

Answer 17

14% of all DKA admissions more frequent admissions for DKA, more likely to miss taking insulin prior to admission, higher admission glucose

Question 18

risk factors for DKA leading to ER visit/hospitalization

Answer 18

A1C; african american; female; psychiatric disorder; under insured; limited self care skills; illness; substance abuse

Question 19

physical exam for DKA

Answer 19

temperature; tachycardia; orthostatic BP/hypotension; dry mucosa; fruity odor of breath; abdominal pain; drowsiness–>coma; heme positive stool?

Question 20

why heme positive stool?

Answer 20

gastric bleeding from retching, from vomiting, Hct is concentrated d/t increased urination, will start to dilute once return fluids so don’t necessarily thing with drop in Hct and heme positive stool that its a GI bleed

Question 21

what mOsm do you have decreased LOC

Answer 21

if decreased level of consciousness with eosm < 320 look for other source of change in mental status

generally see decreased LOC with mOsm > 320

Question 22

what does corrected sodium tell you?

Answer 22

helps evaluate severity of dehydration use measured Na for anion gap, not the calculated corrected Na.

Question 23

anion gap acidosis

Answer 23

ketoacidosis, lactic acidosis, chronic renal failure, salicylate, methanol, ethylene glycol, paraldehyde

Question 24

what is winter’s formula?

Answer 24

if the equation doesn’t equal the resulted PCO2 then you have to think of something besides just a standard acid base imbalance

Question 25

causes for mixed acid base issues

Answer 25

respiratory alkalosis - PNA; metabolic alkalosis - vomiting, diuretics

Question 26

treatment goals for DKA

Answer 26

rehydrate; correct hyperglycemia; reverse ketosis; replace electrolytes;

Question 27

how fast should you change serum osmolality in DKA?

Answer 27

3 mOsm/kg H2O/hour goal replace ~50% deficit in 8 hours

Question 28

fluid choice for DKA replacement?

Answer 28

NS then NS or 1/2 NS based on clinical assessment/volume status/urine output/labs

Question 29

which takes longer to clear, ketones or hyperglycemia

Answer 29

ketones

Question 30

when do you start giving D5W in DKA?

Answer 30

when plasma glucose reaches 200 mg/dL; administer D5W at 100-200 mL/hour; giving D5W allows us to keep the insulin drip at a higher rate and to get rid of ketones faster.

Question 31

concerns for insulin and K+?

Answer 31

K+ should be \> 3.3 before giving insulin. bolus is optional: 0.1 units/kg regular insulin 0.1 units/kg/hr regular insulin as continuous infusion or 0.14 units/kg/hr if NO bolus decrease rate of insulin infusion when glucose is 200. goal is to decrease glucose ~50-75 mg/dL/hr (if it goes to fast worry about osmotic shifts especially in the brain)

Question 32

do you give bicarbonate for DKA?

Answer 32

not routinely recommended. no improvement in outcome pH\>6.9 but no studies evaluating outcome with pH\<69

Question 33

what happens to phosphate with DKA

Answer 33

normal to increased at presentation. decreases with treatment

Question 34

how do you treat low phosphate?

Answer 34

with potassium phosphate only if low

Question 35

complications of treating for low phosphate

Answer 35

hypocalcemia, metastatic calcification, hypomagnesemia

Question 36

do you replace low calcium in DKA?

Answer 36

only if symptomatic w/ calcium gluconate

Question 37

what lab studies you order in DKA?

Answer 37

CBC, CMP, ABG, serum/urine ketones (for initial diagnosis, likely will go up when getting better), Q1H glucose, Q1-2H K+, Q2-4 hr electrolytes, calcium, phosphate, magnesium culture of blood, urine, sputum as indicated (to figure out infection as the precipitating factor to DKA)

Question 38

what do you trend to know when to stop iv insulin?

Answer 38

bicarbonate, stop when bicarb is \> 18 & patient tolerating PO

Question 39

complications of treatment?

Answer 39

hypoglycemia, hyponatremia/hypernatremia, hypokalemia, hyperchloremia, hypotension (you want to correct this first before giving IV insulin), cerebral edema

Question 40

what happens during recovery of DKA?

Answer 40

hyperchloremic metabolic acidosis. loss of ketones in urine & loss of buffering capacity Cl- is reabsorbed leading to hyperchloremic acidosis will likely resolve on its own over a couple of days

Question 41

most feared complication of DKA

Answer 41

cerebral edema. most common \< 5 year old; rare in patients \> 20; occurs only 1% of the time & more common in newly diagnosed diabetics

Question 42

why do you do hourly neuro checks?

Answer 42

cerebral edema - can have headache; impaired LOC; bradycardia; elevated blood pressure; urinary incontinence; vomiting; unequal/fixed dilated pupils

Question 43

risk factors for cerebral edema with DKA

Answer 43

1. treatment with HCO3 2. bad initial pCO2 3. bad initial BUN (r/t dehydration) not r/t rate of sodium or glucose correction

Question 44

when should you start long active sub Q insulin?

Answer 44

start subQ2-3 hours prior to stopping IV insulin IV insulin only lasts 20 minutes in blood stream

Question 45

what does basal insulin do?

Answer 45

controls glucose and ketone production between meals and overnight; withholding basal insulin in insulin deficient patients results in rapid rise in glucose and DKA should be about 50% of daily insulin requirements

Question 46

what does prandial insulin do?

Answer 46

insulin required to cover meals; limits post prandial hyperglycemia; 10-20% of total daily insulin requirement at each meal

Question 47

what does correction/supplemental insulin do?

Answer 47

used to correct hyperglycemia; used in combination w/ long acting insulin; should be adjusted based on recent glucose levels, previous insulin requirements & changes in patient's medical condition

Question 48

how do you calculate starting dose of basal insulin?

Answer 48

weight based, 50/50 basal/nutritional. ranges from 0.3 with malnourished, no h/o DM, cognitive impairment to 0.6 units/kg/day to DM2, obese & on glucocorticoids

Question 49

what is the goal blood glucose?

Answer 49

140-180

Question 50

how do you figure out basal insulin based on IV insulin infusion?

Answer 50

project 24 hour requirement based on most recent 4 hour period, do 80% of TDD; if not eating when receiving the IV insulin multiply that by 2

Question 51

equation for correction/supplemental rapid acting insulin?

Answer 51

=1800/TDD

Question 52

do studies show benefit w/ SSI?

Answer 52

nope! increase risk of hypoglycemia and hyperglycemia when used alone; it's not proactive - it's responding to hyperglycemia; generally not adjusted based on glucose levels & clinical status

Question 53

flow diagram for hyperglycemic hyperosmolar state

Answer 53

Question 54

when does hyperglycemic hyperosmolar state tend to happen

Answer 54

new/unrecognized diabetes; neglected diabetes; medications; concurrent illness; volume depetion; limited access to fluids; impaired thirst perception

Question 55

what are some drugs causing hyperglycemia

Answer 55

glucocorticoids; cyclosporine/tacrolimus; sirolimus; everolimus; protease inhibitors, clozapine, TKI, bevacizumab, diuretics

Question 56

predisposing factors for HHS

Answer 56

female; acute infection, NH resident; dementia

Question 57

HHS clinical manifestations

Answer 57

polyuria, polydipsia, dehydration, neurological abnormalities; heme positive stool; normal temperature; lethargy & disorders of sensorium

Question 58

HHS treatment

Answer 58

fluids, insulin (not as critical since not producing ketones like DKA)

Question 59

reasons for early mortality in HHS

Answer 59

sepsis, shock, underlying illness,

Question 60

causes of late mortality in HHS

Answer 60

thrombosis d/t dehydration, hypercoagulable state

Question 61

HHS management

Answer 61

depends on reason for HHS safest to start on sub Q when stopping IV insulin depending on other medical conditions and if total insulin dose is \<30 might be able to switch to oral diabetic medicaion

Question 62

considerations for non-insulin therapies

Answer 62

sulfonylureas can prolong hypoglycemia metformin contraindicated w/ decreased renal function, use of iodinated contrast dye, and any state of poor tissue perfusion thiazolidinediones are associated w/ edema and CHF GLP1 can cause N/V & act by lowering post prandial glucose so less effective is patient is NPO SGLT2 may cause hyperkalemia and hypovolemia b/c it increases glucose in the urine

Question 63

sick day management for diabetics

Answer 63

take diabetes medication even if eating less check glucose at least 4 times a day, more often for severe illness check ketones if glucose \>250 push fluids (sugar free if able to eat, w/ sugar if can't eat) call health care provider: presistent vomiting/diarrhea; BS \> 250 x 2 checks of BS does not decrease w/ extra insulin; moderate/large ketones

Question 65

what is stress hyperglycemia?

Answer 65

no prior history of diabetes; inpatient hyperglycemia (check A1C to see where they've been); follow up testing for DM w/in 1 month of hospital discharge

Question 66

adrenergic symptoms of hypoglycemia

Answer 66

palitations; diaphoresis; anxiety; agitation; hunger; tremor; pallor

Question 67

neuroglycopenic symptoms of hypoglycemia

Answer 67

fatigue/listlessness; inappropriate behavior; cognitive impairment; focal neurologic deficits; seizure; loss of consciousness; death