Pharmacotherapy III: DKA and Inpatient Diabetes

125, 180

Hyperglycemia is defined as BG > ____ or PPBG > ____.

140-180 mg/dL

What BG target is preferred while inpatient to AVOID hypoglycemia risk?

A, B, C, D

Which of the following are challenges when it comes to treating hyperglycemia for patients in the hospital? SATA.

(a) patient on meds that worsen hyperglycemia (NE, steroids)

(b) patient is experiencing acute stress

(c) changes in nutritional status (NPO, etc.)

(d) variability in fingerstick results

ventilation, steroids, vasopressors, TPNs, diuretics, stress

What may contribute to hyperglycemia in acutely ill patients WITHOUT underlying diabetes?

DKA, HHS

What are two hyperglycemic crises in patients WITH underlying diabetes?

DKA (diabetic ketoacidosis)

An endocrine disorder characterized by breakdown of fat for fuel and the resulting byproducts are acidic ketones.

1

DKA is more common in patients with type ___ diabetes.

hyperglycemia, dehydration/hypotension/electrolyte loss, lipolysis

What are some signs and symptoms of DKA?

fruity breath, high ketones, metabolic acidosis, severe NV

What are some signs of lipolysis?

unknown diabetes, medications, disease states

What are some possible reasons why a patient may find themselves in DKA?

steroids, antipsychotics

What are some medications with a risk of hyperglycemia that may contribute to DKA risk?

HHS (hyperglycemic hyperosmolar syndrome)

A serious condition resulting from extremely high blood sugar levels without the presence of ketones.

2

HHS is more common in patients with type ___ diabetes.

ketones

What lab value is normal in HHS that is super high in DKA?

hypovolemia, hypotension, 3 Ps, AMS

What are some signs and symptoms of HHS?

noncompliance, new acute illness, poor sick day management

What are some possible reasons why a patient might go into HHS?

HHS

Which hyperglycemic crisis has a slower onset?

HHS

Which hyperglycemic crisis presents more with altered mental status?

DKA

Which hyperglycemic crisis presents more with nausea, vomiting, or abdominal pain?

HHS

Which hyperglycemic crisis presents more with the 3 Ps?

DKA

Which hyperglycemic crisis presents more with kussmaul respiration (deep, fast respirations used to blow off CO2, which acidifies the blood)?

T (about 1/3 of all patients!)

T or F: Patients can present with both HHS and DKA.

advanced beta cell failure

T2DM patients are more at-risk for developing HSS AND DKA at the same time if they have...

profound dehydration or late presentation for care

T1DM patients are more at-risk for developing HSS AND DKA if they have...

BG > 180, normal A1C/no hx of diabetes, identifiable cause of stress, in the ICU

How do we define a critically ill patient from a non-severe patient when they present with hyperglycemia?

DKA

A glucose > 250 mg/dL is more indicative of (HHS/DKA).

HHS

A glucose > 600 mg/dL is more indicative of (HHS/DKA).

HHS

An arterial pH > 7.3 is more indicative of (HHS/DKA).

DKA

An arterial pH < 7 is more indicative of (HHS/DKA).

DKA

A serum bicarbonate < 10 is more indicative of (HHS/DKA).

HHS

A serum bicarbonate > 18 is more indicative of (HHS/DKA).

HHS

Very high serum osmolality (> 320 mOsm/kg) is more indicative of (HHS/DKA).

DKA

A higher anion gap (> 10-12) is more indicative of (HHS/DKA).

Na - (Cl + bicarb)

How can you calculate the anion gap?

human regular insulin IV infusion

What is the preferred treatment in a NON-diabetes patient with acute hyperglycemia?

0.1 units/kg/hr

What DOSE of insulin infusion is preferred?

variable absorption

Why is subQ insulin no longer preferred?

basal-bolus insulin

What insulin can be administered in a NON-diabetes patient with acute hyperglycemia if they are normotensive?

when they leave the ICU

When can we d/c insulin in NON-diabetes patients with acute hyperglycemia?

140-180

Once again, what is our BG goal when the patient is in the ICU?

fluids, hyperglycemia, electrolytes, acidosis

What FOUR treatment strategies are recommended when treating HHS/DKA?

0.9% NaCl infused at 1 L/hr

What fluid is recommended in the treatment of HHS/DKA?

D5W + 0.45% NaCl

If a patient's BG dips below 300, consider changing the fluid to _________ instead of 0.9% NaCl.

IV insulin infusion at 0.1 units/kg

What treatment is recommended to manage hyperglycemia in HHS/DKA?

K, P

What two electrolytes do we monitor closely and correct in DKA/HHS treatment?

3.5

If potassium is < ___, we should administer short infusions to rectify it.

short infusions of 10-20 mEq in 100-250mL fluid over 1 horu

How should we administer K if below 3.5?

muscle weakness, respiratory compromise

When do we consider administering phosphorous in HHS/DKA management?

0.08-0.215 mmol/kg infused slowly over 2-6 hours

How is phosphorous administered in the treatment of DKA/HHS?

complete other therapies first and calculate anion gap

What should be done for acidosis management in DKA?

6.9-7, 50 mmol of bicarbonate

If the anion gap is between __-___, you should administer ____________.

6.9, 100 mmol bicarbonate

If the anion gap is < ___, you should administer ___________.

STOP oral diabetes medications

What is the first step in people with hyperglycemia NOT in the ICU?

basal-bolus insulin

What medication should be initiated in people with hyperglycemia NOT in the ICU?

T

T or F: If a patient is not on any form of nutrition, you should hold prandial/bolus insulin.

QID

How often should BG be measured per day in the treatment of hyperglycemia NOT in the ICU?

insulin infusion

Which insulin is preferred for hyperglycemia treatment IN THE ICU?

insulin infusion

Which insulin is preferred for hyperglycemia treatment IN HHS/DKA?

basal-bolus insulin

Which insulin is preferred for hyperglycemia treatment NOT IN THE ICU?

acute hyperglycemia NOT from diabetes with normotensive BP

When can basal-bolus insulin be used in the ICU?

4.8x increase in mortality

Why do we want to avoid hypoglycemia in inpatient diabetes treatment?

monitor every 1-2 hours and reduce insulin if BG < 250

How should we monitor for hypoglycemia?

K follows insulin into cells

Why do we see lower amounts of K once treatment for hyperglycemia begins?

q4hr

How often should we check K values during an insulin infusion?

prophylactic LMWH

HHS and DKA are both pro-thrombotic states. What can be added onto therapy to prevent thrombosis?

cerebral edema

A rare side effect of HHS/DKA due to osmotic changed that has high mortality.

AMS (altered mental status)

How can we monitor for cerebral edema?

mannitol, intubation

What can we use to treat cerebral edema if developed in HHS/DKA?

osmotic demyelination syndrome

A syndrome that may occur with too-rapid correction of hyponatremia.

0.9% saline solution

How can we treat osmotic demyelination syndrome?

AKI

A complication that occurs in > 50% of all patients with DKA/HHS.

resolves with proper hydration

How do we treat AKIs associated with HHS/DKA?

hypoglycemia

The most severe treatment-related adverse event of DKA/HHS.

stage 4 CKD, varying dietary intake, intense insulin therapy

Which patients are at a higher risk of developing hypoglycemia from insulin inpatient treatment?

tachycardia, tremors, AMS, coma, seizures

What are some symptoms of hypoglycemia?

15g fast acting carbs

If BG < 70, what should you do to treat?

15, 80

After administering carbs, check FBG in _____ minutes and repeat until > ___.

glucagon or IV dextrose

If a patient's BG < 54, how should you treat hypoglycemia?

15, 80

After administering glucagon or dextrose, you should recheck FBG in ____ minutes and repeat until > ___.