pc5 1.10 acute complications of diabetes

infection, noncomplicance, new dx, alcohol misuse, stress, pregnancy, CVD events, trauma, meds, pancreatitis

trigger for hyperglycemia complication

absolute

is DKA an absolute or relative insulin deficiency

relative

is HHS an absolute or relative insulin deficiency

alcoholic ketosis, starvation ketosis, hypoglycemia ketosis, SGL2i induced eDKA

what can lead to ketosis

DM, HHS< stress hyperglycemia, impaired glucose tolerance

what can lead to hyperglycemia

lactic acidosis, hyperchloremic acidosis, toxic ingestion related acidosis, drugs, uremic acidosis

what can lead to acidosis

DKA

is DKA or HHS seen more often in T1DM

HHS

is DKA or HHS seen more often in T2DM

DKA

is DKA or HHS seen in younger patients more often

HHS

is DKA or HHS seen in older patients more often

DKA

does DKA or HHS have a quicker onset

HHS

does DKA or HHS have higher mortality

infection, noncomplicance, new dx

most common precipitating factors for HHS/DKA

cost, understanding, psychological effects of disease, eating disorder, diet, monitoring

reasons for insulin noncompliance

diabetes/hyperglycemia, ketosis, metabolic acidosis

diagnostic criteria for DKA involves what 3 criteria

glucose 200mg/dL or higher, OR prior history of diabetes

in DKA what criteria qualifies for the Diabetes/hyperglycemia criteria

B hydroxybutyrate concetration of 3 or more, OR urine ketone strip of 2 or more

in DKA what criteria qualifies for the ketosis criteria

pH under 7.3 and/or bicarb under 18

in DKA what criteria qualifies for the metabolic acidosis criteria

yes

does fluid loss occur in DKA

euglycemic DKA

Diabetic ketoacidosis with normal blood glucose levels.

fasting, pregnancy, drug intoxication, stress from surgery/infection, SGLT2i

when is euglycemic DKA seen

under 250

BG level in euglycemic DKA

200 or higher

glucose level for mild, moderate, and severe DKA

3-6

what B hydroxybutyrate level indicates mild DKA

3-6

what B hydroxybutyrate level indicates moderate DKA

over 6

what B hydroxybutyrate level indicates severe DKA

7.25 to 7.30

what pH indicates mild DKA

7.0 to 7.25

what pH indicates moderate DKA

under 7.0

what pH indicates severe DKA

15-18

what bicarbonate level indicates mild DKA

10-14.9

what bicarbonate level indicates moderate DKA

under 10

what bicarbonate level indicates severe DKA

alert

what mental status indicates mild DKA

alert/drowsy

what mental status indicates moderate DKA

stupor/coma

what mental status indicates severe DKA

hyperglycemia, hyperosmolarity, sbsence of significant ketonemia, absence of acidosis

criteria for HHS includes what categories

all 4

how many categories of criteria must a patient have to qualify for HHS

BG 600 or higher

(higher than DKA)

in HHS what criteria qualifies for the hyperglycemia category

calculated effective serum osmolality over 300 or total serum osmolality over 320

in HHS what criteria qualifies for the hyperosmolaritycategory

2Na(mmol/L) + glucose(mmol/L) or 2 [Na] + glucose (mg/dL)/19

equation for calculated effective serum osmolality

2Na (mmol/L)+ glucose(mmol/L) + urea(mmol/L) OR 2[Na] + glucose(mg/dL)/18 + BUN(mg/dL)/2.8 - PC4 formula

equation for total serum osmolality

B hydroxybutyrate concentration under 3.0 or urine ketone strip under 2+

in HHS what criteria qualifies for the absence of significant ketonemia category

pH 7.3 or higher, bicarb 15 or higher

in HHS what criteria qualifies for the absence of acidosis category

profound dehydration BUN over 30, creatine over 1.5, alteration in consciousness

outside the criteria, what are additional features of HHS

both

does DKA or HHS have polyuria, polydipsia, weight loss, and dehydration

DKA

does DKA or HHS have n/v and abdominal pain

DKA

does DKA or HHS have kussmaul respiration

yes

is a combination common for DKA and HHS

ketonemia

mixed DKA/HHS is defined as meeting criteria for HHS but significant ___ present

b-hydroxybutyrate 3.0+, ketonuria 2+ or higher, pH under 7.3, bicarb under 18

significant ketonemia is shown by what in mixed DKA/HHS

elderly

mixed DKA/HHS is more common in what patients

hyperglycemia, hyperosmolality, fluid shifts, decreased serum sodium, diuresis, acidosis, potassium loss/shift

what phenomena are happening in HHS

fatigue, lethargy, delirium, coma, poor appetite, ha, polyuria, polydipsia, n/v, abdominal pain

signs and symptoms of HHS and DKA

kussmaul breathing, fruity breath

symptoms specific to DKA

restore circulating volume/perfusion

what is the first goal of DKA therapy

resolve hyperglyemia and ketoacidosis, correct electrolyte imbalances and ketosis

what is the second goal of DKA therapy

treat underlying cause

what is the third goal of DKA therapy

restore circulating volume and perfusion

what is the first goal of HHS therapy

resolve hyperglycemia, electrolyte imbalances, and prevent cerebral edema pontine myelinolysis

what is the second goal of HHS therapy

treat underlying causes

what is the third goal of HHS therapy

pontine myelinolysis

non inflammatory demyelination with basis pontis

quadriplegia, palsy, encephalopathy, coma

what can pontine myelinolysis cause

Na

pontine myelinolysis comes as a result of raising what too quickly

Na increases

how does decreasing glucose level for HHS/DKA treatment affect Na levels

HHS

is there greater diuresis and volume loss in HHS or DKA

1 L NS bolus over 1 hour, then 500-1000mL/hr for 1-3 hours

initial fluid tx for severe hypovolemia in DKA and HHS

tachycardia, BP under 90/60

what is severe hypovolemia indicated by

NS or balanced crystalloid at 500-1000mL/hr first 2-4 hours

initial fluid tx for mild hypovolemia in DKA and HHS

cardiac compromise

when evidence of renal or cardiac dysfunction need more advanced intervention with hemodynamic monitoring and vasopressors is seen in DKA or HHS

bp, HR, fluid input/output balance, sodium concentration/osmolality

subsequent fluid replacement in DKA/HHS tx depends on state of hydration which is assessed by what

24-48 hours

for subsequent fluid replacement in DKA/HHS losses should be replaced over what time

5-10% dextrose

for subsequent fluid replacement in DKA/HHS what should be given when glucose is 250 or less

isotonic saline

for fluid replacement in DKA/HHS is isotonic saline or balanced crystalloids more common

local availability, cost, resources

why is isotonic saline more common for fluid replacement in DKA/HHS tx

need to be compounded if need more potassium

considerations in using balanced crystalloids for fluid replacement in DKA/HHS

serum Na + (1.6 x [glucose-100]/100)

equation for corrected Na

drop

with rehydration, insulin, and acidosis correction, what is expected to happen to the K concentration

4-5

goal of potassium level in DKA/HHS tx

10-30 mmol/L/h until K over 3.5

if K is under 3.5, what should a patient receive in DKA/HHS tx

10-30mmol/L K in each liter of IV fluid until K 4-5

if K is 3.5-5, what should a patient receive in DKA/HHS tx

start insulin, check serum K every 2 hours

if K is over 5, what should a patient receive in DKA/HHS tx

QT prolongation, ventricular arrhythmias

what does hypokalemia lead to

ventricular arrhythmias, cardiac arrest

what does hyperkalemia lead to

DKA

in DKA or HHS should you calculate an anion gap

Na - Cl - CO2

anion GAP equation

actual Na

what Na level should be used in anion gap equation

no

is bicarbonate recommended for most DKA pts

pH 6.9 or lower

when is bicarbonate considered in DKA pts

in acidosis oxygen disassociates easier in tissues

(bicarb slows this down)

why is bicarbonate not recommended with DKA tx

phosphate under 1.0 with cardiac dysfunction

when is phosphate indicated in DKA tx

insulin decline, hypocalcemia

phosphate replacement leads to what

20-30 mmol

dose of K phos

kphosp has 1.5 mEq of K

considerations of using Kphos for phosphate tx

0.1 units/kg rapid acting insulin as sc bolus then 0.1 units/kg rapid acting insulin analog 1 hr or 0.2 units/kg every 2 hour

initial insulin tx for mild DKA

reduce short acting insulin to 0.05 units/kg/h

tx for mild/moderate/severe DKA or HHS when glucose is under 250

150-200mg/dL

glucose goal for DKA until resolution

consider 0.1 units/kg short acting insulin bolus if delay in starting infusion then 0.1 units/kg/h short acting IV fixed rate insulin infusion

initial insulin tx for moderate or severe DKA

start 0.05 units/kg/h short acting insulin as fixed rate IV infusion

initial insulin tx for HHS

200-250

glucose goal for HHS until resolution

IBW unless underweight

insulin dose for HHS/DKA is based on what weight