ITE Diabetic Ketoacidosis and HHS 3 — Questions and Answers
Question 1: A 55-year-old with type 2 DM on an SGLT2 inhibitor presents with fatigue, nausea, and blood glucose of 210 mg/dL. pH is 7.20, bicarbonate 12, and urine ketones are large. What is this presentation called?
- Starvation ketosis
- Alcoholic ketoacidosis
- Euglycemic DKA (Correct answer)
- Hyperosmolar hyperglycemic state
Correct answer: Euglycemic DKA
Euglycemic DKA, associated with SGLT2 inhibitors, presents with ketoacidosis but relatively normal blood glucose due to glycosuria and altered glucagon/insulin ratio.
Question 2: What is the target rate of serum glucose reduction during the initial phase of DKA treatment?
- 25-50 mg/dL per hour
- 50-75 mg/dL per hour (Correct answer)
- 75-100 mg/dL per hour
- Greater than 100 mg/dL per hour
Correct answer: 50-75 mg/dL per hour
The recommended rate of glucose reduction in DKA is 50-75 mg/dL per hour to avoid rapid osmotic shifts that could precipitate cerebral edema.
Question 3: Which of the following is the most appropriate insulin regimen for mild DKA (pH 7.25-7.30, patient alert and tolerating oral intake)?
- Subcutaneous rapid-acting insulin only (Correct answer)
- IV insulin infusion at 0.1 units/kg/hr
- Subcutaneous basal-bolus insulin regimen
- No insulin; treat with IV fluids alone
Correct answer: Subcutaneous rapid-acting insulin only
Mild DKA in a patient able to eat can be managed with subcutaneous rapid-acting insulin alone rather than IV infusion, per ADA guidelines.
Question 4: A patient with DKA has a corrected sodium of 148 mEq/L. How is corrected sodium calculated in hyperglycemia?
- Add 1.6 mEq/L for every 100 mg/dL glucose above 100 (Correct answer)
- Add 2.4 mEq/L for every 100 mg/dL glucose above 100
- Subtract 1.6 mEq/L for every 100 mg/dL glucose above 100
- No correction needed; measure directly
Correct answer: Add 1.6 mEq/L for every 100 mg/dL glucose above 100
Corrected sodium is calculated by adding 1.6 mEq/L (or 2.4 mEq/L per some guidelines) for every 100 mg/dL glucose above 100 to account for osmotic dilution.
Question 5: A patient with DKA has a serum phosphate of 1.1 mg/dL. Which complication is most closely associated with severe hypophosphatemia in DKA?
- Cardiac arrhythmias
- Respiratory muscle weakness and hemolytic anemia (Correct answer)
- Seizures
- Acute kidney injury
Correct answer: Respiratory muscle weakness and hemolytic anemia
Severe hypophosphatemia in DKA can cause respiratory muscle weakness, hemolysis, and rhabdomyolysis, though routine phosphate replacement is not recommended.
Question 6: When transitioning from IV insulin to subcutaneous insulin at the end of DKA treatment, what is the most important timing consideration?
- Stop IV insulin immediately when anion gap closes
- Give subcutaneous long-acting insulin 2 hours before stopping IV insulin (Correct answer)
- Overlap subcutaneous and IV insulin for 30 minutes only
- Wait until the patient is eating a full meal before any subcutaneous dose
Correct answer: Give subcutaneous long-acting insulin 2 hours before stopping IV insulin
Long-acting subcutaneous insulin should be administered at least 2 hours before stopping IV insulin to prevent recurrence of ketoacidosis due to insulin gap.
Question 7: In DKA, which of the following best explains the Kussmaul breathing pattern seen on examination?
- Pulmonary edema from aggressive fluid resuscitation
- Respiratory compensation for metabolic acidosis (Correct answer)
- Central neurogenic hyperventilation from cerebral edema
- Diaphragm weakness from hypokalemia
Correct answer: Respiratory compensation for metabolic acidosis
Kussmaul respirations (deep, labored breathing) represent the respiratory system's attempt to blow off CO2 and compensate for the severe metabolic acidosis of DKA.
ITE Diabetic Ketoacidosis and HHS 3
A 55-year-old with type 2 DM on an SGLT2 inhibitor presents with fatigue, nausea, and blood glucose of 210 mg/dL. pH is 7.20, bicarbonate 12, and urine ketones are large.
What is this presentation called?