DKA And Hyperglycemic Hyperosmolar

Question 1

What are SIX precipitating factors of DKA/HHS?

Answer 1

Infection
New presentation of DM (usually kids w T1)
Insufficient insulin therapy
Pancreatitis
Acute CV events
Medications

Question 2

What are some key signs and sx of DKA?

Answer 2

Quick onset (hrs-days)
Kussmaul breathing
acetone breath
N/V
Abdominal pain
(Shared: Hypothermia, tachycardia, altered mental, polydipsia, polyuria, weight loss)

Question 3

What are some key signs and sx of HHS?

Answer 3

**slower onset (days-weeks)
Hypotension
(Shared: Hypothermia, tachycardia, altered mental, polydipsia, polyuria, weight loss)

Question 4

What are some lab finding with DKA diagnosis?

Answer 4

BG >250
Acidosis
Low serum bicarb
(+) urine ketones
Anion gap >12

Question 5

What are some lab finding with HHS diagnosis?

Answer 5

BG > 600
Serum osmolarity > 320mOsm/kg
Altered mental status

Question 6

What is the ANION GAP equation?

Answer 6

Na - (Cl + HCO3)
Aka cations - anions

Question 7

How do we correct for serum sodium in DKA/HHS?

Answer 7

+1.6 mEq Na for every 100mg BG over 100mg/dL

Question 8

What is the serum osmolality equation?

Answer 8

2xNa + (glucose/18) + (BUN/2.8)

Question 9

What are the three overarching steps to treating DKA/HSS?

Answer 9

1. Hydration
2. Correct hyperglycemia
3. Fix electrolyte imbalances

Question 10

When rehydrating DKA/HSS patients, what agents should we use? What if their chloride levels are too high?

Answer 10

Gold standard = NS
High chloride = use 1/2 NS

Question 11

What are the steps to using insulin inpatient to correct hyperglycemia?

Answer 11

1. 0.1 U/kg IV bolus + 0.1 U/kg/hr infusion
   OR
   0.14 U/kg/hr (no bolus)
2. Increase infusion rate each hour if BG doesn’t decrease by 50-75 mg/dL in hour 1
3. Once BG 200-250 mg/dL (DKA) or 250-300 mg/dL (HHS) then decrease infusion to 0.05 U/kg/hr + add D5W until resolution

Question 12

Normal potassium levels are 4-5 mEq/L. What do we do if the K+ <3.3?

Answer 12

Hold insulin and give 10-20 mEq/hr

Question 13

Normal potassium levels are 4-5 mEq/L. What do we do if the K+ = 3.3-5.2?

Answer 13

Give 20-30 mEq K+ in each liter of fluid to maintain K+

Question 14

Normal potassium levels are 4-5 mEq/L. What do we do if the K+ > 5.2?

Answer 14

Avoid giving any K+, check levels q2hrs

Question 15

Why do we have to watch potassium levels in hyperglycemic emergencies?

Answer 15

Insulin therapy causes K+ to shift from extracellular space to intracellular, decreasing serum K+ availability

Question 16

Bicarb administration during DKA/HSS has not been shown to improve outcomes, but when may it be considered?

Answer 16

If pH <6.9
D/C when venous pH >7.0
*note: may cause hypokalemia and increase risk of cerebral edema

Question 17

What are the end point goals of DKA?

Answer 17

BG < 200 mg/dL AND 2 of the following:
- Bicarb ≥15 mEq/L
- pH > 7.3
- Anion gap ≤ 12 mEq/L

Question 18

What are the end point goals of HHS?

Answer 18

Serum osmolality < 320 mOsm/kg
Recovery of mental status

Question 19

What is the process when transitioning stabilized hyperglycemic pts to SQ insulin?

Answer 19

When crisis is resolved, pt is alert and able to eat
May resume home insulin regimen if appropriate (ie. Pt wasn’t adherent so crisis)
If starting new regimen = 0.4-0.5 U/kg/day with 40-50% as basal insulin
*when transitioning, overlap infusion and SQ insulin for ~2 hrs!

Question 20

What are THREE complications of hyperglycemic crisis treatments?

Answer 20

Hypoglycemia
Hypokalemia
Cerebral edema (mostly in children w DKA)

Question 21

What is euglycemic DKA? What is its presentation?

Answer 21

Uncommon complication associated with extreme fasting, surgery pregnancy and SGLT2i use
Presentation: normal BG + metabolic acidosis, lower bicarb levels and (+) urine ketones

Question 22

How do you treat euglycemic DKA?

Answer 22

Same as normal DKA, but initiate D5W immediately to avoid hypoglycemia