Critical Care: DKA and HHS

Question 1

Precipitating factors of DKA/HHS

Answer 1

• Infection
• Initial presentaion of DM
• Insufficient insulin therapy
• Pancreatitis
• Acute CV events
• Meds
  
  • GC
  • Atypical APS
  • Beta blockers
  • Thiazides
  • Simpathomimetics

Question 2

General DKA and HHS signs

Answer 2

• hypotherma, tachycardia, AMS

AMS always present in HHS, sometimes in DKA

DKA specific: Kussmaul breathing (deep rapid breathing) and acetone breath

Question 3

DKA and HHS symptoms

Answer 3

• polydipsia
• polyruia
• weakness
• weight loss

Question 4

DKA labs

Answer 4

• BG > 250
• pH < 7.30
• bicarb < 18
• urine ketone (+)
• anion gap > 12

Question 5

HHS labs

Answer 5

• BG > 600
• serum osmolality >320
• NORMAL pH, bicarb
• NO urine ketones

Question 6

most significant difference between DKA nd HHS

Answer 6

time of onset
- dka: hrs - days
- HHS: days - weeks

Question 7

goals of DKA/HHS treatment

Answer 7

• hydration
• correct hyper BG and ketosis
• fix electrolyte imablance

Question 8

complications of DKA/HHS treatment

Answer 8

• Hypoglyvemia
• Hypokealemia
• Cerebral edema (mostly in children)

Question 9

euglycemia DKA treatment

Answer 9

• basically the same as DKA/HHS only you start with D5W for IV fluid instead of NS or LR

Question 10

potassium correction in treatment fo DKA//HHS

Answer 10

• K < 3.3: hold insulin and give 10-20 mEq/hr of K until > 3.3
• K 3.3-5.2: give 20-30 mEq in each L of IV fluid to keep K between 4 and 5

monitor K closely

Question 11

when to give pt bicarb when treating DKA/HHS

Answer 11

only if pt pH < 6.9

ADR of bicarb treatment: hypo K and cerebral edema

Question 12

DKA/HHS hydration treatment

Answer 12

• 500-1000 ml/hr of LR or NS during first 2-4 hrs
  
  • Dude if you receive 3L of NS → iatrogeneic hypochloremia and worse SCr outcomes
  • Can be reduced to 250 ml/hr if needed
  • Can use 1/2 NS if normal to high Na

Question 13

why do DKA/HHS pts need IV hydration

Answer 13

• expand intravascular volume
• improve renal blood flow
• reduce insulin rsistance

Question 14

DKA/HHS insulin IV therapy

Answer 14

1. (0.14 U/kg/hr infusion) OR ( 0.1 U/kg IV bolus followed by 0.1 U/kg/hr IV - preferred)
2. assess pt BG after QH - if BG does NOT decrease by 55-75 U, increase infusion rate
3. continue insulin IV until BG at goal (DKA: 200-250 / HHS: 250-300)
4. reduce insulin IV infusion rate to 0.02-0.05 U /kr/hr AND admin D5W IV
5. continue until resultion of DKA/HHS

Question 15

DKA resolution

Answer 15

BG < 200 and 2 of the following
- bicarb > 15
- pH > 7.3
- anion < 12

Question 16

HHS resolution

Answer 16

• serum osmolality < 320
• pt mentally alert

Question 17

DKA/HHS insulin SQ therapy

Answer 17

• started once pt has achieved resolution of DKA/HHS
• consider home regimen if appropriate, if new insulin start: TDD = 0.4-0.5 U/kg/day split 50/50ish between basal and prandial
• discontinue IV insulin therapy about 2 hrs after first dose of basal SQ insulin