DKA

Question 1

DKA

Answer 1

• Diabetic Ketoacidosis
• Typically affects people with DM I
• Causes 200,000+ ED visits each year
• Mortality: 1-5%

Question 2

HHS

Answer 2

• Hyperosmolar Hyperglycemic State (HHS)
• Typically affects DM II
• 20,000+ ED visits

Question 3

Insulin Insufficiency

Answer 3

• Without insulin, we can’t utilize glucose
• Metabolism shifts to alternative energy sources
• Insulin binds to insulin receptors and causes a signal transduction that allows glucose to enter cells
• Allows for glucose utilization and glycogen/lipid/protein synthesis

Question 4

Diagnostic Criteria for DKA

Answer 4

• Blood glucose > 250
• Arterial pH < 7.3
• Serum bicarb < 18
• Anion Gap > 10
• Ketones: Positive
• Hours to days of onset

Question 5

HHS Diagnostic

Answer 5

• Blood glucose > 600
• Serum osmolality > 320
• Days to weeks of onset
• Altered mental status

Question 6

Euglycemic DKA

Answer 6

• “Normal” Serum Glucose
• SGLT2-i
• Ketosis and acidosis

Question 7

Anion Gap Calculations

Answer 7

• Normal: 7-9
• > 10-12 indicates anion gap metabolic acidosis
• AG = Na - Cl - HCO3

Question 8

Serum Osmolality

Answer 8

• Normal: 285-295
• > = 320 is hyperosmolar
• Serum Osmolality: 2[Na] + ([Glu]/18) + ([BUN]/2.8)

Question 9

Treatment Goals DKA/HHS

Answer 9

1. Rehydration => fluid resuscitation: expansion of volumes and restoration of renal perfusion
2. Correct hyperglycemia => insulin: promote uptake of glucose into cells, stop production of ketones
3. Management of Electrolyte and Acid/Base Imbalance: prevention of hypokalemia and consider bicarbonate for severe acidosis
4. Identification of Precipitating Events: underlying infection, non-adherence, heavy drug/alcohol use

Question 10

Fluid Resuscitation

Answer 10

• NS 15-20 mL/kg over first hour
• NS or 1/2NS 250-500 mL/hr until blood glucose is normal
• D5 or 1/2NS at 125-250 mL/hr until DKA resolves

NS if [Na] is low and 1/2 NS if [Na] is normal

Question 11

Corrected Na Calculation

Answer 11

Measured Na + (Serum glucose - 100/100)*1.6

Question 12

Potassium Replacement

Answer 12

• Goal: 4-5 mEq/L
• Replacement when < 5.2
• 20-30 mEq K per L
• May also supplement PO or IV infusion: 10 mEq = 0.1 mEq/L
• If potassium is < 3.3, insulin treatment should be delayed

Question 13

Acid/Base Imbalances

Answer 13

• Acidosis will resolve with fluids and insulin
• Use of bicarbonate in DKA is controversial: insulin and fluids usually enough to acidosis
• Bicarbonate has lots of risks like hypokalemia, decreased tissue oxygen uptake, and cerebral edema
• If pH >= 6.9: no sodium bicarb
• If pH is lowering them 100 mEq sodium bicarb in 400 mL of sterile water with KCl until pH > 7

Question 14

Regular Insulin

Answer 14

-0.1 u/kg IV bolus + 0.1 u/kg/hr continuous IV infusion
OR
-0.14 u/kg/hr continuous IV infusion
-Goal: Decrease blood glucose by 50-75 mg/dL per hour
-Then decrease to 0.02-0.05u/kg/hr continuous IV infusion (also where you switch fluids to D5 or 1/2NS)
-DKA: blood glucose between 150-200 until resolution
-HHS: blood glucose between 200-300 until resolution

Question 15

DKA Resolution Lab Values

Answer 15

• Serum glucose < 200
• pH normalized > 7.3
• Anion gap closure < 12
• Serum bicarb > 18

Question 16

HHS Resolution Lab Values

Answer 16

• Normal osmolality

- Return to normal mental status

Question 17

Transition to SQ Insulin

Answer 17

• IV insulin infusion should be continued until hyperglycemic crisis is resolved
• Ensure patient is able to tolerate oral nutritional intake prior to transistion
• Overlap IV and SQ insulin by 1-2 hours to prevent returning DKA/HHS
• Dosing varies by insulin use

Question 18

SQ Insulin Dosing

Answer 18

• Insulin-naive: 0.5-0.8 u/kg/day

- Previous insulin use: may use previous dose, if adequate