Hyperglycemic Crises and Inpatient Control of Diabetes

Question 1

What is DKA

Answer 1

Diabetic Ketoacidosis
Complication in T1 pts
Hyperglycemia + Ketosis + Acidosis

Question 2

Pathophysiology of DKA

Answer 2

Decreased insulin concentration

Increased counterregulatory hormones

Question 3

Counterregulatory hormones

Answer 3

Catecholamines
Cortisol
Glucagon
Growth Hormones

Question 4

DKA Hyperglycemia from

Answer 4

Increased glyconeogenesis
Accelerated glycogenolysis
Impaired glucose utilizaiton

Question 5

DKA Lipolysis from

Answer 5

Insulin deficiency

Counterregulatory hormones

Question 6

DKA Transient insulin resistance from:

Answer 6

Hormone imbalance

Elevated FFA

Question 7

Increased FFA oxidation in liver leads to

Answer 7

Increased ketone bodies (beta-hydroxybutyrate and acetoacetate) which leads to acidosis

Question 8

DKA symptoms

Answer 8

N/V
Ab pain
Polyuria
Polydispsia
Confusion
Fatigue
Fruity odor on breath (ketones)

Question 9

DKA presentation

Answer 9

Elevated glucose
Low arterial pH
Low serum bicarbonate
Elevated anion gap
Decreasing mental status
Decreased sodium
Increased phosphate

Question 10

Treatment Goals

Answer 10

Correct dehydration, hyperglycemia, electrolyte imbalances
ID and correct precipitating factors
Frequent pt monitoring

Question 11

Treatment Initial Fluid Therapy

Answer 11

Initial: Normal Saline 15-20 mL/kg/hr or 1-1.5 L in the first hr

Question 12

Treatment Maintenance Fluid Therapy

Answer 12

1/2 NS at 250-500 mL/kg OR NS at 250-500 mL/hr if low serum Na
Once glucose is ~200 mg/dL –> add 5% dextrose to fluids
Correct fluid deficits within 24 hrs

Question 13

Treatment Insulin Therapy

Answer 13

Initial IV bolus of regular insulin 0.1u/kg
Continuous infusion regular insulin 0.1u/kg/hr
When serum glucose reaches 200, decrease insulin to 0.02-0.05 u/kg/hr
Maintain glucose between 150-200

Question 14

Treatment Potassium Replacement

Answer 14

Replace K+ when levels fall below UNL
20-30 mEq/L fluid maintenance
Goal: 4-5 mEq/L
Delay insulin until K+ is >3.3 bc it pushes it intracellularly

Question 15

Treatment of Bicarb and Phosphate Replacement

Answer 15

Bicarb: pH < 6.90

Phosphate is pushed intracellularly by insulin

Question 16

Transitioning to SQ insulin

Answer 16

Glucose < 200 + 2 of the following:
Bicarb >15
pH >7.3
Anion gap <12

Overlap for 1-2 hrs

Question 17

If insulin naive:

Answer 17

Start multi-dose insulin regimen at 0.5-0.8 u/kg/day

Question 18

Cerebral Edema Signs and Symptoms

Answer 18

Headache
Level of consciousness deterioration
Seizures
Incontinence
Pupilary changes 
Bradycardia
Decreased BP

Question 19

Prevention of Cerebral Edema

Answer 19

Avoid excessive hydration
Avoid rapid reduction in plasma osmolarity
Gradual decrease in serum glucose
Maintain glucose at 250-300 until mental status normalized

Question 20

Treatment of Cerebral Edema

Answer 20

Mannitol infusion

Mechanical ventilation

Question 21

What is HHS

Answer 21

Hyperglycemic Hyperosmolar Syndrome
Usually from restricted water intake
Days to weeks
Dehydration- osmotic diuresis
Relative insulin deficiency (prevents lipolysis -- no acidosis)

Question 22

Presentation of HHS

Answer 22

Hemiparesis and seizures
A lot higher glucose than DKA
Normal pH
Normal bicarb
High osmolarity --> diuresis
Worse mental status

Question 23

Treatment for HHS

Answer 23

Fluid therapy: NS or 1/2 NS
Once glucose is ~300 add dextrose
Insulin therapy: Decrease rate when glucose is ~300

Question 24

Challenges to inpatient glycemic control

Answer 24

Acute illness
Inconsistent caloric intake
Changes in medications
Limitations in glucose monitoring and insulin administration

Question 25

Goals in Critically Ill Patients

Answer 25

Initiate IV insulin when BG >180 mg/dL
BG target = 140-180
Avoid hypoglycemia

Question 26

Goals in Non-critically ill patients

Answer 26

Fasting BG <70

Question 27

Management

Answer 27

Oral meds may need to be discontinued upon admission

Sliding scale insulin alone is not appropriate for hospitalized patients

Question 28

Management of Critically ill patients

Answer 28

Continuous IV insulin is preferred method in this population

Question 29

Management of Non-Critically Ill Patients

Answer 29

SQ insulin preferred (basal/bolus)