DKA and HHS

Question 1

Diabetic Ketoacidosis

Answer 1

Absolute insulin deficiency
onset: hrs - days
Clinical picture:
- polyuria
- polydipsia
- weight loss
- weakness
- AMS
- Kussmaul respirations
- N/V
- abdominal pain
Glucose: > 250
Acidosis: pH < 7.3
Anion gap > 12
Ketones: +
Serum osmolality: <320 mOsm/kg

Question 2

Hyperosmolar Hyperglycemic State (HHS)

Answer 2

Relative insulin deficiency
onset: days - weeks
Clinical picture:
- vomiting
- dehydration
- neuro manifestations (seizures)
glucose: > 600
acidosis: normal
anion gap: variable
ketones: -
serum oslolality: > 320 mOsm/kg

Question 3

Pillars of therapy for DKA and HHS

Answer 3

fluid management
insulin therapy
potassium management
bicarb
phosphate

Question 4

Initial fluid management

Answer 4

15-20 mL/kg for the first hour

Question 5

fluid management: severe dehydration

Answer 5

NS at 1L/hr

Question 6

fluid management: mild dehydration

Answer 6

serum Na+ normal or high: 1/2 NS 250-500mL/hr

serum Na+ low: NS 250-500 mL/hr

Question 7

Fluid management: What level should blood glucose be at before therapy is stepped down to 1/2 NS/D5W at 150-250 mL/hr?

Answer 7

DKA: 200
HHS: 300

Question 8

Insulin therapy: starting regular insulin dosing

Answer 8

0.1 U/kg as an IV bolus then 0.1 U/kg/hr continuous infusion

OR

0.14 U/kg/hr continuous IV infusion

Question 9

Goal glucose decrease from regular insulin therapy

Answer 9

decreasing by 50-75 mg/dL/hr

if not achieved within first hour, increase the infusion every hour until steady decline is achieved

Question 10

Stepping down regular insulin: what dose and when?

Answer 10

What dose: 0.02-0.05 U/kg/hr

When:
- DKA: BG 150-200
- HHS: BG 200-300

Question 11

In DKA when should you switch from IV to SQ insulin

Answer 11

When BG < 200 + 2 of the following:
- serum bicarb >/=15
- pH > 7.3
- anion gap </= 12

Question 12

In HHS when should you switch from IV to SQ insulin?

Answer 12

normal osmolarity and normal mental status

Question 13

Insulin IV to SQ transition: Hx of DM with insulin

Answer 13

overlap SQ with IV infusion for 1-2 hrs

continue home dosing if previously controlled
generally start with a reduced dose due to less food intake at hospital

Question 14

Insulin IV to SQ transition: insulin naive

Answer 14

overlap SQ with IV infusion for 1-2 hrs

Multidose regimen with basal (glargine or detemir) + bolus (lispro, aspart, glulasine) at dose of 0.5-0.8 U/kg/day

Question 15

how often should blood glucose readings be taken?

Answer 15

every hour

Question 16

potassium management: K<3.3

Answer 16

hold insulin and replete K at 20-30 mEq/hr until K > 3.3

Question 17

potassium management: K 3.3-5.3

Answer 17

20-30 mEq K given with every liter of fluid

Question 18

potassium management: K > 5.2

Answer 18

do not give K until below ULN

Question 19

Sodium bicarb

Answer 19

only indicated if pH < 6.9

100 mmol in 400 mL of H2O + 20 mEq of KCl over 2 hrs
- repeat every 2 hrs until pH >/= 7

Question 20

Phosphate management

Answer 20

20-30 mEq/L potassium phosphate added to fluids

Indications:
- cardiac dysfunction
- anemia
- respiratory depression
- serum phosphate < 1.0 mg/dL