Diabetes

Question 1

BG in DKA vs HHS

Answer 1

DKA 300-500
HHS over 1000

Question 2

Normal glucose metabolism

Answer 2

Glucose inc with diet, insulin is released from the pancreas, dec gluconeogenesis and glycogenolysis and inc glucose uptake by skeletal muscle and adipose tissue

Question 3

DKA

Answer 3

insulin is less effective because there isn’t it any
- ketoacidosis and hyperglycemia

Question 4

HHS

Answer 4

Ineffective insulin; have enough to not get ketoacidosis but not enough to control blood glucose

Question 5

Counterregulatory hormones

Answer 5

Released under bodily stress
- catecholamines, cortisol, glucagon, GH
- causes inc glucose prod and impaired glucose use in peripheral tissues

Question 6

Why does dehydration occur with HHS?

Answer 6

osmotic diuresis from glycosuria

Question 7

Ketoacidosis sx

Answer 7

SOB, ab pain, N/V from inc gluconeogenesis, lipolysis, ketogenesis, dec glycolysis

Question 8

Is DKA or HHS treated sooner?

Answer 8

DKA because get symptoms earlier from ketoacidosis

Question 9

pH with ketoacidosis and DKA

Answer 9

Under 7.3

Question 10

How does GFR affect DKA?

Answer 10

Can excrete glucose better, often while younger

Question 11

s/s HHS

Answer 11

hypotension, hypoperfusion, weakness, n/v, ab pain, hypothermia, inc BUN and crt, neuro sx, FVD, polyuria, polydipsia, wt loss

Question 12

Potassium with HHS

Answer 12

• early or normal hyperK
• later possible hypoK

Question 13

Patho of HHS

Answer 13

• relative ins deficiency
• osmotic diuresis
• hyperosmolality
• serum K high or normal and dilutional hypoN
• neuro sx bc dehydration

Question 14

Tx for HHS

Answer 14

• 0.9% NS
• potassium (if sx or at least 4)
• IV insulin—drive K back into cells

Question 15

rf for HHS

Answer 15

• mostly type 2, >65 (inadequate ins or infx w/o ins adjustment)
• predisposed to PNA, UTI, MI, sepsis, inflam
• meds that affect carb met like steroids, thiazide diuretics, SGLT2i, cocaine and subs
• nonDM w/ predispose fx like pancreatitis

Question 16

When is HHS resolved?

Answer 16

• can eat
• can transition back to SQ insulin
• serum osmolality <315
• mentally alert

Question 17

DKA s/s

Answer 17

• BG 250-450 or over 600
• rapid onset over 24h (dx sooner)
• polyuria, polydipsia
• n/v, abd pain—delayed emptying or ileus from met acid
• AMS, obtunded w/ severe acidosis
• FVD
• fruity breath from exhaled acetone
• compensatory hypervent
• pH<7.3
• coma and death

Question 18

patho of DKA

Answer 18

• lack ins
• release counterreg hor
• b/d fat into FFAs and glycerol, proteolysis
• ketone bodies accum
• met acidosis
• anion gap
• hyperosmolality
• osmotic diuresis
• electrolyte imbalance
• neuro sx from dehydration

Question 19

How does met acidosis occur with DKA?

Answer 19

• lipolysis occurs as glucose can’t get into cells
• FFAs form and become acetyl CoA then ketone bodies
• ketone bodies accumulate in blood
• ketones are acidic
• exacerbates K imbalance bc H+ pushes K+ out of cell to balance

Question 20

What activates FFAs?

Answer 20

hepatocytes of the liver

Question 21

Anion gap

Answer 21

Difference between negative (Cl- and bicarb) and Na+ ions

Question 22

How is anion gap measured

Answer 22

with beta hydroxybutyrate—main met product of ketoacidosis

Question 23

Fx that affect severity of acidosis

Answer 23

• rate and duration of ketone production
• rat of ketone metabolism
• rate of ketones in urine (depend on fluid vol and GFR_

Question 24

What speeds up the rate of ketoacids lost in urine?

Answer 24

isotonic fluids

Question 25

Electrolyte imbalance from DKA

Answer 25

K is high or normal and Na is dilutionally low - osmotic diuresis causes loss of Na, K, and H2O

Question 26

DKA tx

Answer 26

0.9% NS - With dextrose if gluc <200 and pt still has anion gap Potassium (if symptomatic or at least 4) IV insulin - Watch for hypoglycemia and frequently monitor VS Sodium bicarb if pH <7.2 or difficulty breathing - Careful of overshoot as insulin is given

Question 27

rf for DKA

Answer 27

- ppl<65 and type 1 mostly (inadequate ins, infx w/o ins adjust) - t2 extreme conditions - predisp to PNA, UTI, MI, sepsis, stroke, inflam, infx - emotional stress - steroids, thiazide diuretics, SGLT2i, cocaine sub abuse)

Question 28

How do you know when DKA is resolved?

Answer 28

- anion gap closed - ketoacidosis fixed - can eat - can take SQ ins again

Question 29

Patho for microvascular comps

Answer 29

- hypoxia and ischemia - microangiopathy---thick, weak cap membranes - freq and sever of damage depends on disease duration

Question 30

Neuropathy

Answer 30

- most common - ischemia and demyelination of nerves - lose pain, temp, vibratic sens - ulcer, infx, amputation

Question 31

retinopathy

Answer 31

- lead blindness - hypoxemia, damage to retinal BVs, RBC agg and HTN - small vessel infarc and death

Question 32

Nephropathy

Answer 32

- leads to CKD and ESRD - GBM thick and hard

Question 33

Macrovascular comps

Answer 33

- athero lead to CAD, PVD, stroke, infx - inc inflam - oxidative stress, endothelial dysfxn, alter mineral metab, inc cytokine prod

Question 34

Patho of infx in diabetics

Answer 34

- tissue hypoxia and impaired skin integ from neuropathy---healthy cells can't get there - pathogens feed on excess gluc and fewer WBCs circ