Endo Emergencies (DKA and HHS)

ketone, acidosis, 1, children, adherence, education, increased, infection, stress

DKA General Info

• Life threatening emergency

• Increased body ________ concentration and metabolic __________

• May be the initial manifestation of type _ diabetes, especially in _____________

• Commonly occurs with poor treatment ___________ in pts with type 1 diabetes, particularly when episodes are recurrent

  • Poor treatment adherence can be attributed to psychological factors or poor pt __________

• Primarily develops in type 1 diabetics with ______________ insulin requirements

  • Insulin requirements increase during ____________, trauma, myocardial infarction, or surgery

• May develop in type 2 diabetics under severe _______ such as sepsis or trauma

hyperglycemia, acidemia, ketonemia

What is the DKA triad?

polyuria, polydipsia, fatigue, abdominal, dry, hypotension, Kussmaul, Fruity

DKA Signs and Symptoms

• Earliest symptoms of marked hyperglycemia: _________, ___________, and _________

• Mental stupor

• N/V

• ___________ pain

• Dehydration

  • ___ mucus membranes

  • _____________

• _____________ respirations

  • Deep and compensatory hyperventilation to offset acidosis

• “________” breath odor

  • Due to exhaled acetone

250, 800, anion gap, ketonemia

DKA Diagnostics

• ______________ > ___ mg/dL

  • Commonly 350-500 mg/dL

  • Usually less than ___ mg/dL

• ________ ___ Metabolic Acidosis

  • Blood pH <7.3

  • Serum bicarbonate <15 mEq/L

• __________

  • Serum (+) for ketones

mild, moderate, severe

DKA Staging

• ____ DKA

  • pH 7.25-7.30

  • HCO3 15-18

• __________ DKA

  • pH 7.00-7.24

  • HCO3 10-15

• _________ DKA

  • pH <7.00

  • HCO3 <10

replacement, potassium, insulin, bicarbonate

DKA Treatment

1. Fluid ____________

2. _____________ Replacement

3. _________

4. ______________

normal saline, slow, half normal, crystalloids, hyperchloremic

DKA Treatment → Fluid Replacement

• At least 1 L of 0.9% saline (_______ ________) per hour in the first 1-2 hrs to re-expand contracted vascular volume

• After the first 2 L of fluid have been given, ____ the IV infusion rate to 300-400 mL/hr

• Use 0.9% (normal) saline unless serum sodium is >150 mEq/L, when 0.45% (____ __________) saline solution should be used

  • Early balanced ____________ is a reasonable alternative to reduce risk of ___________ acidosis

BEFORE, potassium, into, hypokalemia

DKA Treatment → Potassium Replacement

• Do this ________ administering insulin if ____________ level is <3.3

  • Insulin will shift potassium ____ the cells and worsen the _____________

potassium, bolus, IM, 6.9, 7.1

DKA Treatment

• Insulin Replacement

  • Remember not to start insulin until the ____________ level is at least > 3.3 mEq/L

  • Begin with loading dose of 0.1 unit/kg as IV _______, followed by 0.1 unit/kg/hr, continuously infused or given hourly as an __ injection

• Bicarbonate

  • Administer NaHCO3 through infusion ONLY if the arterial blood pH is < _._

  • Repeated until the arterial pH reaches _._

cerebral, children, baseline, rapid, volume, deterioration, mannitol, diuretic, pulmonary, respiratory

DKA Complications

• Symptomatic __________ edema

  • Occurs primarily in ____________

  • Risk factors include severe __________ acidosis, _______ correction of hyperglycemia, and excess _________ administration in the first 4 hrs

  • Consider if headache or ____________ in mental status occur during treatment

  • Treat with IV __________

    • A ________ that creates and ongoing osmotic gradient that reduces cerebral edema and decreases intracranial volume

• Excess crystalloid infusion can precipitate ___________ edema

• Acute ___________ distress syndrome is a rare complication of treatment for DKA

40, older, education, ketonuria, fluids, infection, high, pump

DKA Prognosis and Prevention

• Prognosis

  • Mortality rate <5% in pts < __ years old

  • Mortality rate >20% in _______ patients

• Prevention

  • Pt ___________ and intensive counseling

    • Contact a provider for persistent __________, vomiting, or inability to keep down _________

  • Urine ketones should be measured in the following scenarios

    • Signs of __________

    • Persistently _____ blood glucose in pts treated with insulin _____

acute, 2, infection, corticosteroids, diuretics, kidney, higher, worsens

Hyperglycemic Hyperosmolar State (HHS)

• _______ complication of diabetes

• Often seen in older pts with type _ diabetes

• Less common than DKA

• Often precipitated by ____________, stoke, surgery, MI, and even some drugs (phenytoin, diazoxide, _____________, and __________)

• Acute _______ dysfunction develops from hypovolemia, leading to increasingly ________ blood glucose concentrations

• Underlying chronic kidney disease or HF is common, and the presence of either ____________ the prognosis

gradual, weakness, polyuria, polydipsia, acidosis, pain, Kussmaul, neurological, lethargy, coma, reduced

HHS Signs and Symptoms

• Usually more __________ onset than DKA

  • ___________, ___________, and ____________ over days or weeks

• NO _____________ → therefore no abdominal ____ or ___________ respirations

• More pronounced ___________ symptoms than DKA

  • ___________ and confusion if serum osmolality >310 mOsm/kg

  • Convulsions and ____ if osmolality >320-330 mOsm/kg

• ___________ fluid intake

  • May be from inappropriate lack of thirst, nausea, or inaccessibility of fluids to pts who are bedridden and frail

800, 1000, serum, acidosis, ketones, neurologic

HHS Diagnostics

• Severe hyperglycemia, usual serum glucose > ___ mg/dL

  • May exceed ____ mg/dL

• _______ osmolality >310 mOsm/kg

  • May get as high as 380 mOsm/kg

  • Normal is 2750295 mOsm/kg

• No _________ → blood pH >7.3

• Serum bicarbonate >18 mEq/L

• __________ are minimal or absent

• Remember, it often presents with __________ abnormalities

Fluids, urinary, fluids, increasing, excretion, bolus, hour, DKA, elevated

HHS Treatment

• IV ________

  • As much as 4-6 L of fluid may be required in first 8-10 hrs

  • Goal of fluid therapy is to restore __________ output to > 50 mL/h

• Insulin

  • Do not start until after _________ replaced

  • Fluid replacement alone can reduce hyperglycemia by _____________ glomerular filtration and renal ___________ of glucose

  • Start the insulin infusion rate at 0.05 units/kg/h (_______ is not needed) and titrate to lower blood glucose levels by 50-70 mg/dL per _____

  • Less insulin is required than in ___ coma

• Potassium

  • Add potassium chloride to initial fluids if serum potassium is not ___________ (since you are giving them insulin)

dehydration, output, fluid, MI, embolism, thrombosis, rhabdomyolysis

HHS Complications

• Complications may result from severe ____________ and low ________ state

• _______ replacement is the primary approach to preventing these complications

• Potential complications

  • __

  • Stroke

  • Pulmonary ___________

  • Mesenteric vein ___________

  • Disseminated intravascular coagulation (DIC)

• ________________ should also be looked for and treated

higher, older, dehydration, underlying, metabolic, extremes, predispose, small, increasing, clinician

HHS Prognosis and Prevention

• Prognosis

  • Mortality rate is 10-20%, which is 10x _________ than that for DKA

    • Due to its higher incidence in _______ pts and greater ___________

  • Mortality is primarily d/t the ____________ precipitating illness and only rarely to the __________ complications of hyperglycemia

  • The prognosis of hyperglycemic crisis is substantially worse at the _________ of age and in the presence of coma and hypotension

• Prevention

  • Pt Education

    • If the pt has known diabetes, educate about the situations that could _____________ them to HHS (N/V, infections)

    • Educate how to prevent escalating dehydration

      • Taking _____ sips of sugar-free liquids

      • ____________ usual hypoglycemic therapy

      • Early contact with __________