Endocrine: DKA & HHS

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Author:
jcbarbery
ID:
214885
Filename:
Endocrine: DKA & HHS
Updated:
2013-04-21 17:31:26
Tags:
hyperosmolar hyperglycemic ketoacidosis diabetes endocrine
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Description:
Overview of DKA and HHS
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  1. DKA Epidemiology
    • >136k cases in 2006
    • >500k hospitalization days/year
    • Most common in T1DM @ 18-44 yo
    • Mortality of 4-10%
  2. DKA Precipitating Factors
    • Infxn
    • Omission of insulin or poor DM control
    • New onset DM
    • CVA
    • MI
    • Alcohol abuse
    • Pancreatitis
    • Medications (corticosteroids, thiazides, sympathomimetic agents, antipsychotics)
    • May be unprovoked
  3. DKA Hyperglycemia Pathophys.
    lack of insulin -> glucagon driving carb metabolism -> inc. gluconeogenesis

    May be assoc. w/inflammatory states (elevated proinflammatory cytokines)

    Hyperglycemia -> glycosuria, osmotic diutresis and dehydration w/electrolyte abnormalities
  4. DKA Ketogenesis Pathophys.
    Inc. glucagon -> TG breakdown and Inc. FFAs that blocks lipogenesis -> conversion of FFAs to ketone bodies (weak acids) -> acidosis
  5. HHS Epidemiology
    • Less common than DKA
    • Mortality of 5-20%
    • Most common in T2DM
    • May be initial presentation in up to 40% of pts
  6. HHS Precipitating Factors
    Medical illness that provokes the release of counterregulatory hormones

    Dehydration
  7. HHS Pathophys.
    Similar to DKA

    Elevated Glu in urine -> dec. ability to conc. urine -> further inc. in fluid loss -> dec. kidney perfusion -> extreme renal insufficiency -> worsened hyperglycemia
  8. Common Signs of DKA & HHS
    • 3 Polys
    • Fatigue
    • Dehydration (tachycardia, hypotension)
    • Weight loss
    • Visual disturbances
    • Mental status changes
  9. S/Sx of Acidosis (DKA)
    • Abd. pain
    • N/V
    • Acetone breath
    • Kussmaul respiration
  10. S/Sx of severe dehydration (HHS)
    • Weakness
    • Anorexia
    • Confusion
    • Lethargy
    • Dizziness
    • Dry mucous membranes
    • Poor skin turgor
    • eurodeficits (myoclonic jerk, seizures, aphasia, etc.)
  11. HHS Diff. Dx
    • BG > 600
    • pH > 7.30
    • serum osmolality >320

    • Stupor/coma
    • Total H2O deficit ~9L
  12. Serum Osmolality
    2[Na+K] + glucose/18

    normal: 275-295
  13. Corrected Na
    measured Na +{1.6 x [(glucose-100)/100]}
  14. Anion Gap
    (Na) - (Cl+HCO3)
  15. Elevated BUN:SCr
    generally highest w/HHS
  16. DKA Fluids
    • 1-1.5L 1/2 NS in 1st hour
    • total of 3L over 8h then 3L more over 16h

    Once BG ~200 add D5W to bag

    sub NS if serum Na low
  17. DKA Insulin
    0.1 U/kg IV bolus THEN 0.1 U/kg/hr

    Dec. to 0.02-0.05 U/kg/hr @ <200

    Goal: Dec. BG 50-75/hr

    Continue until ketosis resolved

    Replete K & restore BP 1st

    Hold insulin until K > 3.3
  18. DKA K
    Serum measurements may show as elevated d/t extracellular shift, but stores are depleted

    K will shift intracellular w/insulin admin

    Once K < 5.0 add 20-40 mEq/L of fluids

    If K < 3.3 give 40 mEq in 1st hour then 20/hr until >3.3
  19. DKA Bicarb
    Not supported by lit (may worsen hypokalemia and cause paradoxical CNS acidosis)

    Only use if pH < 6.9

    2 amps (100 mmol)in 400 mL sterile water + 20 mEq KCl over 2 hours until pH > 7
  20. DKA Phosphate
    No clinical benefit

    Indicated in pts w/symptoms of hypophosphatemia (cardiac dysfxn, anemia, muscle weakness, resp. depression)

    ADD 20-30 mEq K Phos to replacement fluids
  21. DKA Resolution
    BG < 200 AND 2+:

    • serum bicarb >/= 15
    • venous pH > 7.3
    • anion gap </= 12
  22. Change to SC Insulin
    • Consider when normal PO intake resumes
    • D/C IV 1-2 hrs after SC admin
    • Resume outpatient regimen w/established DM pts

    Insulin naive: 0.5-0.8 U/kg/day w/basal/bolus dosing
  23. DKA Complications
    • Hypokalemia
    • Hypoglycemia
    • Cerebral edema
    • Fluid overload
    • ARDS
  24. HHS Fluids
    8-12L 2O deficit

    Restore 50% in 1st 12hrs THEN remainder in 12-24 hrs

    20mL/kg NS 1st hr -> 1/2NS if Na normal or volume restored

    Normal rate 4-14mL/kg/hr

    Adequate resuscitation @ 75-100 decrease in BG

    Add D5W @ < 300

    Consider cardiac and renal fxn
  25. HHS K
    Losses greater than DKA

    Manage as DKA
  26. HHS Insulin
    Admin ONLY when hemodynamically stable

    Same as DKA

    Dec. drip once BG < 300

    maintain BG 250-300
  27. HHS Complications
    • Hypokalemia
    • Cerebral edema
    • Thromboembolic events

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