Hyperglycemic Crises

Question 1

Normal Physiological Response to Increased Serum Glucose

Answer 1

Increased serumglucose
Detected by the pancreatic beta cells and insulinwill be released

Question 2

insulin will

Answer 2

↓glucagonsecretionfrom pancreatic alpha cells
↓gluconeogenesis andglycogenolysis in theliver
↑glucoseuptake by muscle andadipose cells

Question 3

Hyperglycemia

DKA & HHS

Answer 3

Results from problems relating to insulin (absolute deficiency or insulin resistance):
↓glucose utilization by peripheral tissues (muscle and adipose cells)
↑glycogenolysis and ↑gluconeogenesis by the liver

Leads to:
↑plasma osmolality (high solute – glucose) → draws water out of the cells → outside the cell the sodium concentration is now dilute

Question 4

hyperglycemia

High serumglucose level (> 180 mg/dL) exceeds renal threshold causing

Answer 4

Glucosuria
Increase inosmotic pressure of the urine leading topolyuria
Loss of water → dehydration → worsens plasma osmolality (hyperosmolality) → potassium shifts out of cells → ↑ extracellularpotassium, ↓ intracellular potassium
Impaired renal function (AKI)

Question 5

DKA

Epidemiology

Answer 5

More frequently seen in younger patients
Mostly seen inpatients with type 1diabetes
Accounts for ~14% of all hospital admissions for diabetics
Mortality rate of 5% in individuals < 40 years; ↑ mortality with advanced age

Question 6

HHS

epidemiology

Answer 6

Usually associated with older individuals (≥ 65 years)
Patientswill usually have type 2 diabetes
Accounts for < 1% of all hospital admissions for diabetics
Mortality rate: 10%–20%

Question 7

HHS & DKA

etiology

Answer 7

Infections(most common)
Inadequate or noncompliance withinsulintreatment
Acute illnesses (stroke,myocardial infarction,pancreatitis, surgery, trauma)
Medications - corticosteroids
Illicit drugs - cocaine
Alcohol

Question 8

HHS

etiology

Answer 8

Dehydration
Medications – diuretics, beta-blockers
Endocrine disorders: Cushing syndrome

Question 9

DKA

etiology

Answer 9

new onset diabetes - type 1

Question 10

DKA

Clin Man

Rapid onset of symptoms (over 24 hours)

Answer 10

Polyuria
Polydipsia
Nausea andvomiting
Diffuse abdominalpain
Weakness
History ofweight loss → common with a new diagnosis oftype 1diabetes

Question 11

DKA

PE Findings

Answer 11

Physical exam findings:
Vitals:
Tachycardia
Hypotension
Hypothermia
Rapid, deep respirations (Kussmaul respirations) → compensatoryhyperventilation (attempting to blow off carbon dioxide – acid)
Fruity breath → exhaledacetone

Question 12

DKA and HHS

Evidence of severedehydration

Answer 12

Dry mucous membranes
Sunken eyes
Decreasedskin turgor
Decreasedurine output

Question 13

HHS

Clin Man

Gradual development of symptoms (over days to weeks)

Answer 13

Polyuria
Polydipsia
Nausea andvomiting

Neurologic changes:
Lethargy
Delirium
Coma(in severe disease)
Seizures
Sensory deficits
Vision changes

Question 14

HHS

PE Findings

Answer 14

Physical exam findings:
Vitals:
Tachycardia
Hypotension
Hypothermia
Altered mental status, lethargy, or coma

Question 15

DKA

Dx

Answer 15

Serum glucose: >250 mg/dL
Serum bicarbonate: ↓↓ (< 18 mEq/L)
Anion gap: Yes(the higher the more severe the presentation)
Serum osmolality: Variable
Serum ketones (beta-hydroxybutyrate, acetone): Positive
Urine ketones: Positive
Arterial blood gas: pH < 7.3; ↓ pCO2 (increase resp to reduce CO2 and lessen acidosis)

Question 16

HHS

Dx

Answer 16

Serum glucose: > 600 mg/dL
Serum bicarbonate: >18 mEq/L
Anion gap: Generally normal
Serum osmolality: >320 mOsm/L
Serum ketones (beta-hydroxybutyrate): Negative or small
Urine ketones: Negative or small
Arterial blood gas: pH > 7.3

Question 17

Dx

Answer 17

both Na will be low, K will be high

Question 18

DKA

IV fluid management

Answer 18

Admit patient to the intensive care unit (ICU)

Aggressive intravenous (IV) fluid replacement:
Begin withnormal saline (0.9% NaCl) (1 L/h for the first 1-2 hours, then run at a rate of ~250 ml/h)
If corrected Na is < 135 mEq/L, continuenormal saline
If corrected Na remains normal or elevated, consider changing to 0.45% saline

Onceglucosereaches 200 mg/dL, change todextrose5 % with ½normal saline at 150–250 mL/hr
Reduces risk ofhypoglycemia
Reduces risk ofcerebral edema (results from rapid decrease inglucose)
Monitorurine output andhemodynamics

fluid is to correct fluid osmolality, which should bring down glucose

Question 19

DKA

IV insulin infusion

Answer 19

K+ must be > 3.3 mEq/L
Regular insulin 0.1 unit/kg as a bolus, then 0.1 unit/kg/h as an infusion or SQ
Hourly serum glucose monitoring
Repeat bolus if the plasma glucose does not ↓ by 10% in the first hour

Close monitoring of serumelectrolytes andanion gap (every 2–4 hours)
High potassium normal corrects with IV hydration and insulin

Providepotassium supplementation to maintain a K of 4–5 mEq/L

albuterol treatments will also bring K back into the cell.

Question 20

DKA

Sodium bicarbonate(NaHCO3)

Answer 20

can be given over 2 hours if the pH is < 6.9

Question 21

DKA

has resolved once..

Answer 21

DKA has resolved once the serumanion gap has normalized (< 12 mEq/L) andglucose is 150–200 mg/dL

Question 22

HHS

IV fluid management

Answer 22

Admit patient to the intensive care unit (ICU)

Aggressive intravenous (IV) fluid administration:
HHSpatients typically have a significant fluid deficit of ~4-10 L
Begin with anormal saline bolus: 1 L over the 1st hour
If the corrected Na is < 135 mEq/L, continuenormal saline
If the corrected Na remains normal or elevated, consider changing to 0.45% saline

Onceglucosereaches 300 mg/dL, change todextrose5% with ½normal saline at 150–250 mL/hr
Maintainglucose between 250 and 300 mg/dL
Monitorurineoutput andhemodynamics

Question 23

Management of HHS

IV Insulin infusion

Answer 23

(K+ must be > 3.3 mEq/L)
Regular insulin 0.1 unit/kg as a bolus, then 0.1 unit/kg/h as an infusion or SQ
Hourly serum glucose monitoring
Repeat bolus if the plasma glucose does not ↓ by 10% in the first hour

Close monitoring of serumelectrolytes (every 2–4 hours)
High potassium normal corrects with IV hydration and insulin
Providepotassium supplementation to maintain a K of 4–5 mEq/L

Question 24

HHS

is considered resolved when..

Answer 24

HHS is resolved when the patient’s mental status has improved, serumosmolalityis < 315 mOsmol/kg, andglucoseis 250–300 mg/dL

Question 25

Question 26