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40 Cards in this Set
- Front
- Back
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What does HHNKS stand for?
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Hyperglycemic, Hyperosmolar, Nonketotic Syndrome
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Normal Blood Glucose range
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70-100
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Give three reasons for hyperglycemia
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1. relative or absolute insulin deficiency 2. impairment of cells' insulin receptors 3. sudden increase in glucose load
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List 6 signs and symptoms of hyperglycemia
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1. polyuria 2. polydypsia 3. polyphasia (cells are starving) 4 weight loss 5. visual changes 6. not healing (phagocytosis is inhibited)
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What is the "prediabetic" fasting blood sugar range?
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100-126
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3 significant complications of diabetes
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amputations, blindness, renal failure
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HbA1C level of 8 means...
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blood sugar has been 200
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What is the DKA blood sugar range?
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300-600mg/dl
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What is the HHNK blood sugar range?
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higher than 600mg/dl
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List some conditions or treatments that can cause a sudden rise in serum glucose
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TPN or PPN, Trauma (because sympathetic nervous system makes blood sugar rise), unresponsive patients (could have hypoglycemia and are given a bolus which sends it too high), steroids
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What is the normal adult daily urine output?
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1.5-2.5 liters per day
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What is glucagon's role in hyperglycemia?
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Glucagon is triggered by insulin deprivation. It initiates hepatic glucose production. The liver dumps more sugar into the bloodstream but the cells still can't take it up without the insulin so the blood sugar rises more.
Glucagon also promotes ketogenesis. Fats are broken down quickly which can lead to ketoacidosis, a form of metabolic acidosis. |
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Who gets DKA?
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1. People who don't know they have diabetes. 2. People who don't or can't comply with meds 3. "Sherlock Holmes" Possibly increased demands from sympathetic NS, infection. 3. Infarction - check troponin levels!
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Name two catecholamines and what they do
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epinephrine and norepinephrine. They are "elevators of glucose" in the sympathetic fight or flight mechanism.
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What is the renal threshold for glucose? What happens when it is reached?
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~160-190 mg/dl is the threshold. Over this the kidneys can't rebsorb glucose and it "spills" out into urine bringing H2O and electrolytes too.
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Why would a hyperglycemic patient get polydipsia?
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Lots of water is being lost in urine due to high blood sugar and renal threshold. Intrecellular and eventually extracellular dehydration occur. Serum Osmolality rises and stimulates thirst center. Patient drinks more liquid.
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Why could K+ be high or low in DKA?
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If low: osmotic diuresis caused the person to pee out the K+
If high: the blood must be acidic (due to ketoacidosis) and excess accumulating H+ ions swapped out with K+ ions which swap into bloodstream |
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How does a patient with DKA look clinically? (signs, symptoms)
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FVD (poor turgor, dry mucous membranes, tachycardia, hypotension, and decreased urinary output)
Fever - makes you think it's an infection Nausea & vomiting Abdominal pain & tenderness Impaired LOC (up to coma) |
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What will Na+ look like in DKA
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For every 100mg increase in glucose level there will be a false 1.6meq/L decrease in sodium level because of a dilutional effect because water is being pulled (by high levels of glucose molecules) into the bloodstream.
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What happens to K+ when you administer IV insulin?
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K+ will go from intravascular to intracellular so you'll have to monitor for hypokalemia and probably have to replace some K+
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What is the anion gap formula and what is a normal anion gap range?
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(Na + K) - (Cl + HCO3) = anion gap
(subtract janor anions from the major cation) Normal range: 8-12mmol/L |
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What happens to anion gap in DKA?
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excess ketoacids make it larger. High anion gap = metabolic acidosis or increased acidity of the blood.
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Labs and EKG in DKA
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BUN & Cr are low
False elevation of Na H&H are high due to hemoconcentration WBC high if there is infection EKG - watch for K+ related changes and tachycardia |
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In DKA which is a better indicator of infection: Fever or WBC?
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WBC. Only 10% of DKA patients with infection have fever.
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Most important aspects of physical exam for a DKA patient?
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vitals, assessing for FVD, LOC, symptoms of hypovolemic shock, signs of infection (WBCs!)
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Most important lab & diagnostic tests for DKA patient?
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glucose, electrolytes, ketones, CBC, BUN/Cr, arterial blood gas, and EKG and lung xray
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Four main components of DKA treatment?
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1. Insulin (regular) 0.05 - 0.2 units/kg/hr IV (usually 100 units of regular in 100cc of 0.9% Normal saline)
2. Fluid for FVD 3. Electrolytes 4. "the dogs" *VERY important: You want 10% decrease in serum glucose per hour - approximately 100mg/hour change - no higher or you risk brain injury due to osmotic differences |
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How much fluid for rehydrating DKA patient?
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one liter of .9% normal saline in first hour for blood volume. Watch Na levels. If serum Na goes over 145meq/l switch to 1/2 normal saline instead. When blood glucose drops to 250-300 switch to dextrose in saline to prevent hypoglycemia.
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Which electrolyte will drop when insulin therapy is started for DKA?
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Potassium. It moves to the ICF causing a drop in the ECF level 1-4 hours from start of treatment. Give 20-40meq of KCl per liter of IV fluid.
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What is the danger of overcorrecting acidosis with bicarbonate therapy?
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Blood brain barrier is impacted. Can cause paradoxical CNS acidosis.
So - unless the Ph is less than 7.1 don't give bicarb! |
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What are "the dogs?" (adverse effects of treatment for DKA)
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cerebral edema
hypokalemia hypoglycemia cardiogenic and non cardiogenic pulmonary edema venus thromosis (blood is thick and hypercoagulable) undiscovered primary problem DIC - Disseminated Intravascular Coagulation (bleeding cascade goes awry - unknown cause) Hypovolemic shock Dysrhythmias FVE Thromboembolism |
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Talk about phosphate in DKA
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Hypophosphatemia is a risk. Must monitor levels. Must replace if less than 1mg/dl. Important role in oxygen delivery to periph tissues. Low levels can depress myocardial functioning. (<2mg/dl)
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Disseminated Intravascular Coagulation - what is it and what are typical labs?
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Leaking blood - the clotting cascade goes awry.
Platelets and Fibrinogen are LOW. PT, PTT, and fibrin split products are HIGH. |
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Serum glucose range for HHNKS
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as high as 600-2000mg/dl
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Clinical presentation for HHNKS
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Serum Osmolality over 340mosmo/kg
Profound dehydration (dry skin, delayed turgor, beefy tongue, sunken eyes, flat neck veins, weight loss, tachycardia, increased resps, decreased BP, narrow pulse pressure |
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Normal CVP
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2-8
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Labs & Diagnostics for HHNKS
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H&H are high (due to hemoconcentration)
BUN and glucose high, Normal bicarb (>20meq/L), Na+ high, K+ normal or low, Anion gap normal, decreased CVP |
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What are the two main priorities for treatment in HHNKS?
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Fluid Replacement (huge priority! but must be careful not to cause FVE in high risk patients)
Insulin Therapy (decrease blood glucose by no more than 50-75mg per hour) |
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What is a special consideration of insulin IV drip?
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You must run 25-50cc of regular insulin into sink because it binds to the inside of tubing. If you don't it would slow the rate of medication getting into the patient if it is binding along the way.
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Name three meds that are known to elevate glucose levels
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steroids
TPN/PPN Thiazide diuretics |
