Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State

What is the most common precipitating cause of DKA?

Errors in insulin use (missed doses, omission, rationing)

Why are children particularly vulnerable to insulin-related DKA?

Missed or omitted insulin doses

Name three major physiologic stressors that can precipitate DKA or HHS

Infection, myocardial infarction, stroke (also trauma or surgery)

Which medication class is associated with euglycemic DKA?

SGLT2 inhibitors

Which counter-regulatory hormones increase during DKA and HHS?

Glucagon, catecholamines, cortisol, growth hormone

What are the major consequences of osmotic diuresis?

Dehydration, hypovolemia, electrolyte abnormalities

What type of insulin deficiency occurs in DKA?

Absolute insulin deficiency

What type of insulin deficiency occurs in HHS?

Relative insulin deficiency

Why does ketosis occur in DKA but not HHS?

Absolute insulin deficiency causes lipolysis and free fatty acid production in DKA

What is the primary ketone body produced in DKA?

β-hydroxybutyrate

Why is β-hydroxybutyrate clinically important?

It is the dominant ketone and best indicator of ketoacidosis severity

What respiratory pattern is characteristic of DKA?

Kussmaul respirations (deep rapid breathing)

Which hyperglycemic crisis typically presents with abdominal pain and vomiting?

DKA

Which hyperglycemic crisis is associated with severe dehydration and altered mental status without ketosis?

HHS

Why is serum osmolality much higher in HHS compared to DKA?

Severe hyperglycemia with minimal ketosis leads to profound dehydration

Which condition develops more rapidly: DKA or HHS?

DKA

Which condition has more severe hyperglycemia: DKA or HHS?

HHS

What are the three core components of DKA/HHS treatment?

IV fluids, insulin, and electrolyte management

Why must the precipitating cause of DKA or HHS be identified and treated?

To prevent recurrence and reduce mortality

Why are IV fluids the first step in DKA management?

They restore intravascular volume and improve renal perfusion

How do fluids help lower blood glucose before insulin is started?

By improving renal glucose excretion

What form of insulin is preferred for initial DKA management?

Continuous IV infusion of short-acting (regular) insulin

What metabolic processes does insulin suppress in DKA?

Hepatic glucose production, lipolysis, ketone formation

Why do DKA patients often present with normal or high serum potassium despite total body depletion?

Acidosis and insulin deficiency shift potassium extracellularly

What happens to serum potassium after insulin therapy is started?

It decreases due to intracellular potassium shift and renal excretion

Why is potassium monitoring critical during DKA treatment?

To prevent life-threatening hypokalemia

How often should potassium be monitored during DKA treatment?

Every 4 hours

Is routine bicarbonate therapy recommended in DKA?

No

When may bicarbonate therapy be considered in DKA?

If pH < 7.0

Why can bicarbonate therapy be harmful?

It increases the risk of hypokalemia and poor outcomes

Why does hypophosphatemia occur in DKA?

Renal phosphate losses due to osmotic diuresis

Is routine phosphate replacement recommended in DKA?

No

What is the risk of rapid phosphate replacement?

Hypocalcemia

How often should blood glucose be monitored during DKA treatment?

Every 1-2 hours

What are the two major complications to actively prevent during treatment?

Hypoglycemia and hypokalemia

Why must IV insulin overlap with subcutaneous insulin in DKA?

To prevent rebound hyperglycemia and recurrent DKA

When should IV insulin be discontinued in DKA?

After anion gap closure and initiation of SQ insulin

What defines euglycemic DKA?

DKA with normal or mildly elevated blood glucose

Which medication class is most associated with euglycemic DKA?

SGLT2 inhibitors

What does "STICH" stand for in SGLT2 inhibitor management?

Stop SGLT2 inhibitor, Insulin, Carbohydrates, Hydration

Why is carbohydrate intake important in the STICH protocol?

To reduce ketone production and support insulin effectiveness

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