Presentation
What are three common reasons for DKA/HHS?
1) Infection
2) Medication compliance
3) Dehydration
What initial labs should be ordered in a patient with DKA?
serum glucose
electrolytes
CBC
UA
plasma osmolality
BBH
ABG
EKG
Which electrolytes are of most concern?
Sodium and potassium
(and phosphate)
SSI
Can also take into account their insulin resistance (ie home dose, severity of DKA, response to insulin)
Your patient who initially presented with DKA now has a blood glucose of 100 at bedtime, the nurse messages you and wants you to hold the long acting insulin that is due now, what do you do?
GIVE IT!
What are symptoms of hyperglycemia?
Polyuria, Polydipsia (early), nausea, vomiting
neuro symptoms (HHS due to greater degree of hyperosmolality), seizures, coma
hyperventilation and abdominal pain in DKA
<800 (between 350 and 500)
Vs HHS >1000
Causes of hypokalemia in DKA?
total body deficit 300-600 mEq
- urinary losses
- insulin shifts K into cells
5% present with hypokalemia (lack of insulin shifts K out of cells so patients may present with normal false K)
<180
Patient presents in DKA with potassium 3.4. What dose of insulin do we start?
0.1 units/kg IV bolus
continuous IV infusion 0.1 units/kg/hour
If no bolus can give 0.14 units/kg/hour
You go to see a patient you're admitting with DKA, what do you assess first when you walk in the room?
ABCs
mental status
volume status
True or false: your patient presents in DKA and with leukocytosis, this must mean they have an infection and we need to start antibiotics
FALSE
May or may not be infection (more likely if WBC >25)
Leukocytosis proportional to degree of ketones, increases with increased cortisol
FALSE
don't forget to correct the sodium
Corrected sodium is 130
What types of medications due we use to treat diabetes in the hospital?
insulin! SSI + Lantus
No PO home meds
What lab value tells us we need to give sodium bicarb?
- Volume depletion (skin turgor, dry mucosa, tachycardia, hypotension)
- Fruity odor
- Kussmaul respirations (compensatory hyperventilation)
What other abnormal lab findings might you see in DKA?
elevated creatinine
elevated amylase, lipase (in up to 1/4)
leukocytosis
elevated lipids - hypertriglycerides (lipolysis d/t insulin def)
True or false: Your patient presents in DKA and initial potassium is 3.2, blood glucose is 500. The first step is to give insulin.
FALSE
Hold insulin
Give KCL 20-40mEq IV until K 3.3
In what scenarios would we use NPH?
To bridge*
true or false: insulin treatment is the same for DKA and HHS?
TRUE
What is the triad of DKA?
Hyperglycemia
Anion gap metabolic acidosis
Ketones
What is Euglycemia DKA and risk factors?
serum glucose near normal
** Still have low insulin and ketoacidosis
- increase risk with poor oral intake, pregnant women, SGLT2 inhibitors
What causes of hypokalemia?
- urinary losses (glucose osmotic diuresis and excretion of potassium ketoacid anion salts)
- insulin treatment shifts K into cells
When do we start SubQ/basal insulin after a patient has been on an insulin drip for DKA? (lab values?)
Ketoacidosis is resolved
Serum glucose < 200
True or false: patients in DKA present with whole body phosphate depletion that we need to make sure to replace right away
FALSE
don't give phosphate routinely
give if severe (<1 mg/dL)