Diabetic Ketoacidosis and HHS Flashcards

A patient with DKA has an initial serum bicarbonate of 8 mEq/L and pH of 7.10. Under which circumstance is sodium bicarbonate administration recommended by most guidelines?

Answer: pH < 7.10 or life-threatening hyperkalemia

Bicarbonate therapy is generally reserved for severe acidosis (pH < 7.0-7.10) or life-threatening hyperkalemia; routine use may worsen outcomes.

A 70-year-old nursing home resident with type 2 DM is found unresponsive. Labs show glucose 1,350 mg/dL, Na 152, osmolality 385 mOsm/kg, pH 7.35, bicarbonate 22. What is the diagnosis?

Answer: Hyperosmolar hyperglycemic state (HHS)

HHS is characterized by extreme hyperglycemia (>600 mg/dL), hyperosmolality (>320 mOsm/kg), and absent or minimal ketoacidosis (pH >7.3, bicarb >18).

Which of the following correctly describes the mortality difference between DKA and HHS?

Answer: HHS has higher mortality than DKA

HHS carries higher mortality (~15%) compared to DKA (~1-5%), largely because it affects older patients with more comorbidities and often presents later.

A patient with DKA has a measured osmolal gap of 22 mOsm/kg (normal <10). Which additional intoxication must be considered?

Answer: Ethylene glycol or methanol poisoning

An elevated osmolal gap in the context of metabolic acidosis should prompt evaluation for toxic alcohol ingestion (ethylene glycol, methanol, isopropanol).

During DKA treatment, a patient's repeat labs show glucose 190, pH 7.28, anion gap 16 (still elevated), and bicarbonate 16. What is the most appropriate action?

Answer: Add dextrose to fluids and continue insulin infusion

Because the anion gap is still elevated, the ketoacidosis has not resolved; dextrose should be added to IV fluids to prevent hypoglycemia while continuing insulin.

Which of the following is the preferred initial fluid for a patient presenting with DKA and hemodynamic instability (BP 80/50)?

Answer: 0.9% NaCl at 1 L/hr bolus

Isotonic 0.9% NaCl is the initial fluid of choice for volume resuscitation in DKA, particularly in hemodynamically unstable patients.

A patient with type 1 DM develops DKA during pregnancy at 28 weeks gestation. Which unique consideration applies to DKA management in pregnancy?

Answer: DKA may occur at lower glucose levels (as low as 200 mg/dL) in pregnancy

Pregnant patients are at risk for 'euglycemic DKA' with lower glucose thresholds due to altered metabolism, increased insulin resistance, and decreased buffering capacity.