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Board Questions

1. What levels of hormones best match those in DKA due to T1 DM? 

a) ↓insulin, ↑ cortisol, ↑ glucagon
b) ↑insulin, ↑ cortisol, ↓ glucagon
c) ↓insulin, ↑ cortisol, ↓ glucagon
d) ↓insulin, ↓ cortisol, ↓ glucagon

2. Your patient’s labs are: 7.28/35/70/16, Na 140 K 4 Cl 116 CO2 16 Glu 200. What is the state of their DKA? 

a) Still in severe DKA
b) Still in moderate DKA
c) Still in mild DKA
d) Resolved

3. What is the primary lab you are tracking to assess response to treatment in DKA? 

a) Bicarbonate level
b) pH
c) Urine Ketones
d) Renal panel 

4. Which of these labs would make you most worried about cerebral edema?

a) Na 130
b) pCO2 8 
c) Bicarbonate 5
d) Glucose 750

5. Your 60kg patient with DKA is on an insulin gtt at 0.1 u/kg/hr, is receiving D12.5NS + 20KCl and 20 KPhos @200 ml/hr. The RN comes to you with a blood sugar of 70. What do you do? 

a) Increase the D12.5 to D15
b) Increase the rate of the D12.5 to 250 ml/hr
c) Decrease the insulin gtt 
d) Give your patient some orange juice



ANSWERS & EXPLANATIONS

1. A. There is a relative lack of insulin and increased counterregulatory hormones such as cortisol, glucagon, and catecholamines that promote further lipolysis, gluconeogenesis, and glycogenolysis.

2. D. The anion gap (Na- Cl - HCO3) has closed as is 8. The patient does have a mild non-gap metabolic acidosis that is likely an iatrogenic hyperchloremic acidosis. Nonetheless, this should not cause significant clinical issues.

3. D The anion gap reflects the degree of ketosis and is the primary lab being followed. While pH, bicarbonate level, and to a lesser extent, urine ketones can be helpful, they may not reflect the actual ketoacidotic state of the patient as demonstrated via the hyperchlroemic non-gap acidosis in question 2. Similarly, the urine ketones may lag behind the actual serum ketones. 

4. C Glaser et al described in their 2001 NEJM article an independent association between low PaCO2 as well as elevated BUN and cerebral edema in patients with DKA. 

5. C While you do not want to shut off the insulin infusion, it is reasonable to decrease the rate of the infusion (ie 0.1 u/kg/hr to 0.05 u/kg/hr). D15 cannot be given peripherally and hence, would not be a good option here. While you could increase the rate of the infusion to 250 ml/hr, the patient is already receiving 2X maintenance fluids and additional fluid may have some association with increased risk of cerebral edema, although this remains controversial. Generally patients are NPO and may not tolerate PO intake when they are in the PICU with DKA, making giving them orange juice not the best option.


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