Maria's DKA lecture

• What is DKA

  Affects mostly Type 1, result of total lack of insulin and increase in counter regulatory hormones that allows hepatic FA oxidation in liver to make 3 main ketone body production, leads to ketoacidosis

  • Acetoacetic acid
  • Beta-hydroxybutyric Acid (from reduction of acetoacetic acid, can measure in blood)
  • Acetone (from decarboxylation of acetoacetic acid, can vaporize and gives "acetone" smell associated with DKA)
• What is HHS

  Mostly type 2, result of relative lack of insulin that causes hyperosmolality, ketones may spill into urine, not enough ketone production to cause ketoacidosis

  • Patient becomes more volume depleted and hyperglycemic
• Difference between DKA and HHS presentation

  DKA: pt usually presents earlier b/c of sx so less dehydration and glucose not as high (<800, usually 350-450)

  HHS: Greater dehydration d/t osmotic diuresis, high glucose (~1000), ketones in urine, enough insulin to prevent lipolysis
• DKA patient findings

  Tend to be younger and have better kidney function, RAPID development, neuro sx, abd pain, dehydration, tachycardia, hypotension, hyperventilation (Kussmaul), fruity breath
• HHS patient findings

  Develop over a longer time period, polyuria/-dipsia, weight loss, neuro sx, dehydration, tachycardia, hypotension
• Precipitating factors for DKA/HHS

  MI, CVA, sepsis, pancreatitis, glucocorticoids, high dose thiazide diuretics, sympathomimetic agents, atypical antipsychotics, SGLT2 inhibitors, cocaine, MDMA

  • M.C. for DKA: infection, new onset T1DM
  • M.C. for HHS: inadequate insulin tx and noncompliance, infection
• Initial evaluation for DKA or HHS

  Airway, breathing, circulation, mental status, precipitating events, volume status
• Labs for DKA or HHS

  glucose, electrolytes (Na, K, creatinine), CBC w/ diff, UA, dipstick, plasma osmolality, beta-hydroxybutyrate, serum ketones, ABG if serum bicarb reduced or hypoxic, EKG
• DKA lab findings

  Anion gap (>20), K and Na imbalance, high glucose >250, low bicarb (15-18), (+) ketones, variable osmolality
• HHS lab findings

  K and Na imbalance, very high glucose (>600), >18 serum bicarb, small amount of ketones, very HIGH osmolality (>320)
• What are the aspects of tx for DKA and HHS

  electrolytes, fluids, insulin, bicarb
• Electrolyte treatment

  • If K <3.3 = HOLD insulin, 20-40 mEq/L/hr added to IVF until >3.3
  • If K 3.3-5.3 = CAN give insulin, 20-30 added to each L of IVF until 4-5
  • If K >5.3 = CAN give insulin, monitor and replace as needed (NOT w/ IVF), check every 1-2 hours, insulin makes K go into cell
• Fluid treatment

  Start w/ 0.9 % NS

  • High/normal corrected Na = 0.45% NS
  • Low corrected Na= 0.9 % NS
  • 0.5% dextrose w/ 0.45% NS once glucose up to 200 (DKA) or 300 (HHS)

  IV rate differences

  • Cardiogenic shock = hemodynamic monitor and vasopressors
  • Severe hypovolemia w/o shock or HF = 1 L/hr, 15-20 mL/kg/hr
  • Mild dehydration/hypovolemia = 250-500 mL/hr
• Insulin treatment

  Rapid or short acting are EQUALLY effective, insulin is the only way to close anion gap

  • Rapid - Lispro (humalog, onset 15-30 mins), Aspart (novolog, onset 10-20 mins)
  • Short - Regular (novolin R, onset 30 mins-1 hr)

  Route can vary

  • If severe - IV bolus (0.1 units/kg) followed y IV infusion (drip, 0.1 units/kg/hr)
  • If mild - subcutaneous insulin
• Bicarbonate treatment

  Controversial

  • pH > 6.9 = NO bicarb b/c as ketones decrease there will be adequate bicarb available
  • pH < 6.9 = give bicarb