ITE Diabetic Ketoacidosis and HHS 5 — Questions and Answers
Question 1: A patient with HHS is treated with IV fluids. After 4 liters of 0.9% NaCl, glucose is 600 mg/dL and osmolality is 340. What is the next most appropriate fluid?
- Continue 0.9% NaCl
- Switch to 0.45% NaCl (Correct answer)
- Switch to D5W
- Switch to D5 0.45% NaCl
Correct answer: Switch to 0.45% NaCl
After initial volume resuscitation with isotonic saline, 0.45% NaCl (hypotonic) is used to replace free water deficit and gradually correct hyperosmolality in HHS.
Question 2: Which electrolyte abnormality is most commonly responsible for fatal cardiac arrhythmias during DKA treatment?
- Hyponatremia
- Hypokalemia (Correct answer)
- Hypophosphatemia
- Hypocalcemia
Correct answer: Hypokalemia
Hypokalemia, resulting from insulin-driven cellular uptake of potassium during DKA treatment, is the most common cause of fatal cardiac arrhythmias.
Question 3: A 45-year-old alcoholic presents with vomiting, abdominal pain, glucose of 95 mg/dL, pH 7.22, and large serum ketones. Which diagnosis is most consistent?
- DKA
- HHS
- Alcoholic ketoacidosis (Correct answer)
- Lactic acidosis from metformin
Correct answer: Alcoholic ketoacidosis
Alcoholic ketoacidosis (AKA) presents with ketoacidosis, near-normal or low glucose, and a history of alcohol use and decreased oral intake.
Question 4: Which criterion must be met before transitioning a DKA patient from IV to subcutaneous insulin?
- Blood glucose < 200 mg/dL
- Anion gap closure AND ability to eat (Correct answer)
- pH > 7.30 only
- Urine ketones negative
Correct answer: Anion gap closure AND ability to eat
DKA resolution requires anion gap closure, pH >7.3, and bicarbonate >18; the patient must also be able to tolerate oral intake before transitioning to subcutaneous insulin.
Question 5: What is the most appropriate initial insulin bolus regimen for moderate-to-severe DKA in an adult?
- IV bolus of 0.1 units/kg followed by infusion at 0.1 units/kg/hr
- Subcutaneous rapid-acting insulin 0.3 units/kg immediately
- IV infusion at 0.14 units/kg/hr without a bolus (Correct answer)
- IM regular insulin 10 units every 2 hours
Correct answer: IV infusion at 0.14 units/kg/hr without a bolus
Current ADA guidelines recommend starting IV insulin at 0.14 units/kg/hr without a bolus as an alternative to the bolus-then-infusion approach, showing equal efficacy.
Question 6: A patient with HHS develops focal neurological deficits during treatment. What is the most likely etiology?
- Hypoglycemia from insulin overdose
- Thrombotic stroke due to hyperviscosity (Correct answer)
- Hyponatremia from aggressive fluid replacement
- Cerebral edema from rapid osmolality correction
Correct answer: Thrombotic stroke due to hyperviscosity
HHS is associated with a hypercoagulable, hyperviscous state that increases risk of arterial and venous thrombotic events, including ischemic stroke.
Question 7: Which finding on urinalysis is LEAST reliable for diagnosing DKA?
- Urine glucose strongly positive
- Urine ketones (nitroprusside reaction) strongly positive (Correct answer)
- Urine specific gravity elevated
- Urine pH low
Correct answer: Urine ketones (nitroprusside reaction) strongly positive
The urine nitroprusside reaction detects acetoacetate but not beta-hydroxybutyrate (the predominant ketone in DKA), so it can underestimate ketosis, especially early in treatment.
ITE Diabetic Ketoacidosis and HHS 5
A patient with HHS is treated with IV fluids.
After 4 liters of 0.9% NaCl, glucose is 600 mg/dL and osmolality is 340.
What is the next most appropriate fluid?