Sugar High (DKA/HHS)

Question 1

DKA definition

Question 2

HHS definition

Question 3

DKA metabolic derrangements

Answer 3

Hypothermia, tachycardia, tachypnea
kussmal breathing, acetone breathing
ileus, AMS

Polydipsia, polyuria, weakness, weight loss, n/v , abdominal pain

Question 4

HHS metabolic derrangements

Answer 4

Hypothermia, tachycardia, hypotension, AMS

Polydipsia, polyuria, weakness, weight loss

Question 5

Prognosis/outcome of DKA/HHS

Answer 5

determined by:
1. severity of dehydration
2. presence of comorbidities
3. age > 60 yo

Question 6

Precipitating factors of hyperglycemic crises

Answer 6

Infection - most common
Initial diabetes presentation (children type 1)
Insufficient insulin therapy
Pancreatitis
Acute CV events (MI, HF, etc)
Medications

Question 7

Medications that precipitate DKA/HHS

Answer 7

Glucocorticoids
Atypical antipsychotics
beta blockers
thiazides
sympathomimetic drugs

Question 8

DKA Labs

Answer 8

BG > 250 mg/dL
pH < 7.3 (acidosis)
Bicarb ≤ 18
( + ) urine ketone
Anion ≥12
+/- AMS

Question 9

DKA vs HHS: time

Answer 9

DKA: hours - days
HHS: days - weeks

Question 10

HHS labs

Answer 10

BG > 600 mg/dL
normal pH/bicarb/anion/ketone
Osmolality >320 mOsm/kg
AMS

Question 11

Anion Gap

Answer 11

Na - (Cl + HCO3)

Question 12

Serum sodium correction

Answer 12

add 1.6 mEq Na for each 100 mg BG >100 mg/dL to measured serum sodium

Question 13

Serum osmolality

Answer 13

2 Na + gluc/18 + BUN/2.8
= mOsm/kg H2O

Question 14

Goals of treatment (DKA/HHS)

Answer 14

hydration
correct hyperglycemia/ketosis
Fix electrolyte imbalances

Question 15

IV fluids benefit

Answer 15

expand volume
improve renal blood flow
reduce insulin resistance

Question 16

IV fluid of choice hyperglycemic emergencies

Answer 16

1. NS
   time to normalize longer with LR
   Less iatrogenic hyperchloremia w/ LR

Question 17

How much IV fluid to give?

Answer 17

500 - 1000 ml/hr NS
given during first 2-4 hours
rate can be reduced to 250 depending on [Na] and hydration

Question 18

Insulin - hyperglycemic emergencies

Answer 18

Initial treatment:
A) 0.1 IU/kg IV bolus + 0.1 IU/kg/hr IV infusion
B) 0.14 IU/kg/hr IV infusion (no bolus)

After first hour: if serum gluc does not decrease by 50-75 = increase IV infusion rate

Once BG drops - decrease IV infusion to 0.02-0.05 U/kg/hr + give D5W* until DKA/HHS resolved
DKA: 200-250
HHS: 250-300

• give D5W to resolve anion gap before using SQ insulin

Question 19

Potassium

Answer 19

monitor closely during treatment – insulin/acidosis correction causes potassium to shift intracellularly

Question 20

Potassium Low

Answer 20

K<3.3
Hold insulin, give K 10-20 mEq/hr
until K>3.3
purpose: avoid cardiac complications

Question 21

Potassium “normal”

Answer 21

K = 3.3-5.2
Give K 20-30 mEq in each liter of IV fluid
Maintain: K 4-5

Question 22

Potassium High

Answer 22

K>5.2
Do not give K, check K every 2 hours

Question 23

Bicarbonate use

Answer 23

Give if pH<6.9
100 mEq in 400 mL sterile water with 20 mEq KCL at rate of 200 ml/hr
Weight based dosing
Give over 2-4 hours until pH 7.2 to 7.3
No benefit seen

Question 24

Bicarbonate risk

Answer 24

may contribute to hypokalemia and risk of cerebral edema

Question 25

DKA endpoint

Answer 25

BG < 200 + 2 of the following
* bicarb ≥15
* pH > 7.3
* Anion gap ≤12

Question 26

HHS endpoint

Answer 26

mOsm/kg < 320
recovery to mental alertness

Question 27

Transitioning to SQ insulin

Answer 27

Once crisis resolved, pt alert, able to eat
New regimen:
- start 0.4-0.5 units/kg/day with 40-50% of TTD as basal and remainder as prandial
Consider resuming home regimen if appropriate
IV insulin continued for 2 hrs after basal insulin dose administered

Question 28

Complications of hyperglycemia crisis treatment

Answer 28

hypoglycemia - D5W
hypokalemia - K
cerebral edema - fatal complication of DKA occurs if fluid shift d/t too rapid glucose correction – often in children

Question 29

Euglycemic DKA (EDKA)

Answer 29

uncommon diabetic complication
Normoglycemia BG<250 + metabolic acidosis (pH<7.3) + decreased bicarb (<18)
Serum/urine ketones elevated (must for diagnosis)

Question 30

Euglycemic DKA risk factors

Answer 30

fasting
surgery
pregnancy
SGLT2i use

Question 31

Euglycemic DKA treatment

Answer 31

same principles as DKA
- insulin correct acidosis/gap
- D5W asap
- electrolyte/dehydration correction