ICC Study Guide

You are so sweet that I just went into DKA w/ coma

What is the initial diagnostic labs and imaging workup for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia?

DKA Labs: BMP (glucose, NA, K, Bicarb), Anion Gap, UA (ketones), Creatinine and BUN
DKA imaging: EKG (hyper/hypokalemia)

What are the “five I’s” of DKA/HSS?

Infection, Ischemia, Insulin Deficiency, Intoxication, Inflammation

What physical exam is required for a patient with an endocrine complaint?

General appearance (signs of cushing's, hydration status, consciousness, growth abnormalities), thyroid exam, diabetic foot exam, skin/hair, eye exam, cardiopulmonary, abdomen, neurologic assessment, etc. Pay attention to vitals, BMI, skin tone, acanthosis nigricans, hirsutism, lymph nodes

How do you differentiate the significance of abdominal pain in DKA and HHS?

DKA abdominal pain can be due to metabolic acidosis, electrolyte distrubances, dehydration, vomiting, etc. HHS typically doesn't present with abdominal pain but when present should raise suspiscion for GI pathology (mesenteric ischemia, pancreatitis, etc.)

What defines the mental status in a patient with DKA?

Weakness, confusion +/- coma

What is the degree of hypovolemia and DKA/HHS?

DKA - 3-6L, HHS - 9-12L

What are the factors when giving fluids to patients with HHS?

volume repletion with LR, replace electrolytes (K and Mg)

When should you start adding dextrose to the IV fluid?

When glucose is ≤ 200 in DKA and ≤ 250 in HHS, and there is still an anion gap

What is the latest evidence on the value of giving an insulin bolus?

Rapid to short acting bolus insulin is used for immediate coverage a for rapid rise in blood glucose with sharp peak and shorter duration of activity

What are the six major actions of insulin?

increase glucose uptake, promote glycogen synthesis, inhibit gluconeogensis, increase lipogenesis, promote protein synthesis, inhibit ketogenesis

When evaluating a patient with hypokalemia, what is the potential EKG abnormality?

U-wave, ST depression, QT prolongation, wide/flat T waves

When evaluating a patient with hyperkalemia, what is the potential EKG abnormality?

prolonged PR interval, tall peaked T waves, flattening to loss of P wave, widened QRS

Under what circumstances should sodium bicarbonate be administered in DKA?

Only if pH ≤ 6.9

Why is euglycemic diabetic ketoacidosis becoming increasingly common?

Use of SGLT2 inhibitors

What is the mechanism of action of a SGLT2 inhibitor?

SGLT2 inhibitors ("-gliflozin") inhibit the sodium glucose cotransporter in the proximal renal tubuless. This blocks glucose reabsorption, enhancing renal excretion of glucose.

What is the expected compensated pCO2 for patients with metabolic acidosis?

Calculate expected PCO2 using WInter's formula: pCO2 = (1.5 x HCO3)+8 +/- 2

What variables are used to calculate serum ion gap?

To calculate anion gap, the formula is (Na - Cl + HCO3)

What variables are used to calculate serum osmolarity/osmolality?

To calculate serum osmolalility/osmolarity, the formula is 2[Na] + Glucose/18 + BUN/2.8

What is the significance of serum osmolality gap?

Suggets there are unmeasured osmoles in the blood, raising suspicion for toxemia or organ damage

What mechanism is used to measure serum osmolarity/osmolality?

Serum Osmolality = 2xNa + Glucose/18 + BUN/2.8

What is the differential diagnosis of anion gapped metabolic acidosis?

GOLDMARK - glycols, oxoproline, l-lactate, d-lactate, methanol, aspirin, renal failure, ketoacidosis

What classification of diabetic medication causes hypoglycemia?

Insulins and sulfonylureas (glipizide, glyburide)

What classification of psychiatric medications causes hypoglycemia?

Atypical antipsychotics (second generation)

What medications are used to treat hypoglycemia secondary to sulfonylurea overdose?

Octreotide (blocks inuslin release), glucagon

What factors contribute to Type 1 diabetes?

Beta cell destruction, genetic predisposition (HLA-DR3. HLA-DQ1, HLA-DR4), chronic pancreatitis, cystic fibrosis, drug or chemical induced

What is the mortality rate for DKA?

5-7%

What is the mortality rate for HHS?

Higher than DKA (no specific # in slides)

What is the common demographic of HHS?

Older Type II Diabetics

What is the duration of onset in HHS?

days to weeks

What is the average fluid deficit in DKA?

≤10 kg = 100-120 mL/kg deficit, 10-20 kg = 80-100 mL/kg deficit, ≥20 kg = 70-80 mL/kg deficit
3 to 6 liters

In the treatment of DKA, at what level of serum glucose are fluids supplemented with dextrose?

If glucose drops less than 250

In the treatment of DKA, what level should potassium be replenished prior to starting to staring an insulin infusion?

Potassium should be > 5.3 mEq/L prior to administering insulin

< 3.3 mEq/L

What medication is used to treat sulfonylurea-induced hypoglycemia refractory to intravenous dextrose?

Octreotide

What is the most likely cause of a 17-year-old girl who administers her own insulin who has presented with DKA 6 times in the past year?

medication noncompliance–teenage girls don't take their insulin regularly in an effort to lose weight, recurrent DKA admissions are a red flag

What is the most appropriate initial action in an elderly patient with a history of diabetes, hypertension, and congestive heart failure presents with a blood glucose of 1100 mg/dL and serum osmolality of 350 mOsm/kg?

Volume repletion with LRs 20mL/kg -> check/correct potassium -> give insulin if glucose is over 600

An 80-year-old patient, with a history of severe abdominal pain, presents with serum glucose of 1100 mg/dL, anion gap of 14, and pH 7.34. His serum osmolarity of 352 mOsm/kg. He has trace urine ketones. What is the significance of abdominal pain in a patient with these lab values?

Patient has HHS (trace ketones = no significant ketoacidosis) which doesn't typically present with abdominal pain. Labs suggest organ-related pathology, thus the abdominal pain likely isn't attributed to hyperglycemia

A DKA patient is given 2000cc IV bolus of 0.9% normal saline solution on arrival. His heart rate has improved and blood pressure has normalized. His corrected serum sodium level is elevated. What is the most appropriate fluid choice for ongoing rehydration?

0.45% NS to lower serum osmoality.

A DKA patient has been receiving normal saline at 500 mL/hr for 2 hours and is on an insulin infusion at 0.1 units/kg/hr. Repeat labs show glucose of 180 mg/dL and the anion gap is 20. What is the most appropriate adjustment in therapy?

Switch fluids to D5 0.45% NS

What is a clear indication for the use of sodium bicarbonate in DKA?

Only if pH ≤ 6.9

What is a clear indication for insulin bolus in DKA?

If you are not using an insulin infusion and need to initiate insulin with subcutaneous rapid-acting insulin, a bolus is required to achieve theraputic levels

What medication causes euglycemic DKA? (serum glucose of 180 mg/dL, pH 7.1, anion gap of 24, and highly elevated serum beta-hydroxybutyrate levels).

SGLT2 inhibitors - cause glucose excretion but also increase ketone production, promotes lipolysis, and reduces insulin levels

How does sulfonylurea affect the pancreas in insulin secretion?

increases pancreatic secretion of insulin by binding SUR1 to close ATP K channel in beta cell membrane which leads to influx of Ca in and insulin out

Why is octreotide used for sulfonylurea overdose?

Sulfonylurea works by binding and blocking the pancreatic beta islet cell potassium channels (ATP-sesnitive). An increase of insulin secretion is obtained by the influx of potassium and depolarization of the cell. Octreotide is a somatostatin analog. Somatostatin works on the pancreas to directly inhibit beta cells from releasing insulin. Somatostatin analogs cause a decrease in cAMP, calcium, and an outflow of potassium: polarization of the cell thus occurs.

How does Lasix cause hypokalemia?

Blocks NKCC2 transporter TAL, leads to excretion of potassium

What medications and electrolytes cause prolonged QT?

Antiarrythmics (class 1a, III), Antibiotics (macrolides), Antipsychotics, Antidepressants, Antiemetics