Sugar High (DKA/HHS) Flashcards
DKA definition
HHS definition
DKA metabolic derrangements
Hypothermia, tachycardia, tachypnea
kussmal breathing, acetone breathing
ileus, AMS
Polydipsia, polyuria, weakness, weight loss, n/v , abdominal pain
HHS metabolic derrangements
Hypothermia, tachycardia, hypotension, AMS
Polydipsia, polyuria, weakness, weight loss
Prognosis/outcome of DKA/HHS
determined by:
1. severity of dehydration
2. presence of comorbidities
3. age > 60 yo
Precipitating factors of hyperglycemic crises
Infection - most common
Initial diabetes presentation (children type 1)
Insufficient insulin therapy
Pancreatitis
Acute CV events (MI, HF, etc)
Medications
Medications that precipitate DKA/HHS
Glucocorticoids
Atypical antipsychotics
beta blockers
thiazides
sympathomimetic drugs
DKA Labs
BG > 250 mg/dL
pH < 7.3 (acidosis)
Bicarb ≤ 18
( + ) urine ketone
Anion ≥12
+/- AMS
DKA vs HHS: time
DKA: hours - days
HHS: days - weeks
HHS labs
BG > 600 mg/dL
normal pH/bicarb/anion/ketone
Osmolality >320 mOsm/kg
AMS
Anion Gap
Na - (Cl + HCO3)
Serum sodium correction
add 1.6 mEq Na for each 100 mg BG >100 mg/dL to measured serum sodium
Serum osmolality
2 Na + gluc/18 + BUN/2.8
= mOsm/kg H2O
Goals of treatment (DKA/HHS)
hydration
correct hyperglycemia/ketosis
Fix electrolyte imbalances
IV fluids benefit
expand volume
improve renal blood flow
reduce insulin resistance
IV fluid of choice hyperglycemic emergencies
- NS
time to normalize longer with LR
Less iatrogenic hyperchloremia w/ LR
How much IV fluid to give?
500 - 1000 ml/hr NS
given during first 2-4 hours
rate can be reduced to 250 depending on [Na] and hydration
Insulin - hyperglycemic emergencies
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
Potassium
monitor closely during treatment – insulin/acidosis correction causes potassium to shift intracellularly
Potassium Low
K<3.3
Hold insulin, give K 10-20 mEq/hr
until K>3.3
purpose: avoid cardiac complications
Potassium “normal”
K = 3.3-5.2
Give K 20-30 mEq in each liter of IV fluid
Maintain: K 4-5
Potassium High
K>5.2
Do not give K, check K every 2 hours
Bicarbonate use
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
Bicarbonate risk
may contribute to hypokalemia and risk of cerebral edema
DKA endpoint
BG < 200 + 2 of the following
* bicarb ≥15
* pH > 7.3
* Anion gap ≤12
HHS endpoint
mOsm/kg < 320
recovery to mental alertness
Transitioning to SQ insulin
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
Complications of hyperglycemia crisis treatment
hypoglycemia - D5W
hypokalemia - K
cerebral edema - fatal complication of DKA occurs if fluid shift d/t too rapid glucose correction – often in children
Euglycemic DKA (EDKA)
uncommon diabetic complication
Normoglycemia BG<250 + metabolic acidosis (pH<7.3) + decreased bicarb (<18)
Serum/urine ketones elevated (must for diagnosis)
Euglycemic DKA risk factors
fasting
surgery
pregnancy
SGLT2i use
Euglycemic DKA treatment
same principles as DKA
- insulin correct acidosis/gap
- D5W asap
- electrolyte/dehydration correction
