Acute Complications of Diabetes Flashcards
What is Diabetic keto-acidosis? (DKA)
- Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes.
- DKA happens when your blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body
DKA is more common in which type of diabetes?
Type 1
What is Hyperosmolar hyperglycaemic state? (HHS)
Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.
Which is rarer, DKA or HHS?
HHS
Diabetic Ketoacidosis: Pathophysiology
- Unchecked gluconeogenesis -> …
- Osmotic diuresis -> …
- Unchecked ketogenesis -> …
- Dissociation of ketone bodies into hydrogen ion and anions -> …-gap metabolic …
- Often a precipitating event is identified (such as?..)
- Unchecked gluconeogenesis -> Hyperglycaemia
- Osmotic diuresis -> Dehydration
- Unchecked ketogenesis -> Ketosis
- Dissociation of ketone bodies into hydrogen ion and anions -> Anion-gap metabolic acidosis
- Often a precipitating event is identified (infection, lack of insulin administration)

Diabetic ketoacidosis- metabolic derangement
Acidosis managed by
- Intracellular … - H+ / K+ exchange
- Potassium hydrogen ion pump
- Respiratory compensation – how?
- H+ stimulates … centres
- … off … (H+ + HCO3- H2O + CO2)
- … excretion of H+ (slow response)
Electrolyte disturbances – renal losses
- Potassium … – maybe >250mmol
- Sodium …
- …
Acidosis managed by
- Intracellular buffering - H+ / K+ exchange
- Potassium hydrogen ion pump
- Respiratory compensation – hyperventilation
- H+ stimulates respiratory centres
- Breathe off CO2 (H+ + HCO3- H2O + CO2)
- Renal excretion of H+ (slow response)
Electrolyte disturbances – renal losses
- Potassium depletion – maybe >250mmol
- Sodium depletion -
- Dehydration
Diabetic Ketoacidosis - Clinical Features
- Age - Mostly … with Type … DM
- Precipitating causes - Relative or absolute … deficiency
- Age - Mostly young T1DM
- Precipitating causes - Relative or absolute insulin deficiency
Diabetic ketoacidosis - Precipitating factors
- Infections - such as … (3)
- Error/ missed … administration
- Myocardial infarction
- Previously undiagnosed …
- Drugs: such as …
- Unidentified
- Infections - pneumonia, urinary tract, viral gastroenteritis
- Error/ missed insulin administration
- Myocardial infarction
- Previously undiagnosed Type 1 diabetes
- Drugs: Steroid
- Unidentified
Diabetic Ketoacidosis - Signs and Symptoms
If the cause is Hyperglycaemia + dehydration, symptoms will be…
- Thirst and …
- Weakness and …
- Drowsiness, …
Signs will be:
- … mouth, … eyes
- … or … hypotension
- Hypothermia & …
If the cause is Hyperglycaemia + dehydration, symptoms will be…
- Thirst and polyuria
- Weakness and malaise
- Drowsiness, confusion
Signs will be:
- Dry mouth, Sunken eyes
- Postural or supine hypotension
- Hypothermia & Coma
Diabetic Ketoacidosis - Signs and Symptoms
If the cause is acidosis, symptoms will be…
- Nausea and …
- … pain
- …
Signs will be…
- Facial …
- Hyper…
- Smell of … on breath and …
If the cause is acidosis, symptoms will be…
- Nausea and vomiting
- Abdominal pain
- Breathlessness
Signs will be…
- Facial flush
- Hyperventilation
- Smell of ketones on breath and ketonuria

Diabetic Ketoacidosis - Clinical Features
- Fill in the table

- Age - Mostly young T1DM
- Precipating causes - Relative or absolute insulin deficiency
- Serum sodium- Normal or low
- Blood Glucose - Usually <40mmol/l
- Serum bicarbonate/pH - <14mmol/l pH<7.3
- Serum ketones - ++++
- Mortality - 5% depending on age
- Subsequent course - Insulin dependent

Acute Complications of Diabetes - Case Study
- What examinations & investigations?

-
Examination & Investigations
- Drowsy, flushed, smelling of ketones, hyperventilating (Kussmaul respiration), still vomiting, vague abdominal pain, succussion splash
- Blood sugar (29mmol/l)
- Urine ketones (++++)
- pH (6.94 - acidodic), pCO2 (4.5 - normal), HCO3 (4 - very low), Lactate (4.1)
- Plasma hydroxybutyrate (7.5 - high (above 3 consistent with DKA))
- Na (144), K (3.1 - low), Urea (5.8), Creat (78), eGFR (>60)
- Hb (138g/l), Wbc (18.9)
Diabetic Ketoacidosis - Management
- Correct the … derangement
- Treat 4 things - what are they?
- Correct the metabolic derangement
- Fix the hyperglycemia, dehydration, acidosis, electrolyte losses (K+)

Diabetic Ketoacidosis - Management - 5 Step Plan:
- Confirm diagnosis and check for … causes
- … & monitor fluid balance
- Iv fluids - saline with added …
- Consider urinary …
- Lower glucose
- Intravenous insulin – fixed rate …Unit/kg/hr
- Monitor …
- Potassium (and sodium)
- Prevent clots
- Prophylactic low molecular weight …
- Confirm diagnosis and check for precipitating causes
-
Rehydrate & monitor fluid balance
- Iv fluids - saline with added potassium
- Consider urinary catheter
- Lower glucose
- Intravenous insulin – fixed rate 0.1Unit/kg/hr
- Monitor electrolytes
- Potassium (and sodium)
- Prevent clots
- Prophylactic low molecular weight heparin
Diabetic Ketoacidosis - Other management factors
- Is the patient …?
- Assess G…
- If concern, call …
- At risk of …
- Consider … tube
- Monitor recovery
- Glucose, ketones, pH, potassium - how often?
- Is the patient conscious?
- Assess GCS
- If concern, call ITU
- At risk of aspiration
- Consider NG tube
- Monitor recovery
- Glucose, ketones, pH, potassium - hourly
Diabetic ketoacidosis - Recovery
- … normal, ketones …2+ (urine), … settled
- Resume normal …
- Switch from intravenous to normal … insulin
- pH normal, ketones <2+ (urine), vomiting settled
- Resume normal diet
- Switch from intravenous to normal subcutaneous insulin
Hyperosmolar Hyperglycaemic State (HHS) - Clinical features
- Fill in the table

- Age - Usually >40years
- Precipitating causes - previously undiagnosed, steroids, diuretics, sugar
- Serum sodium - Usually high
- Blood glucose - Often >40mmol/l
- Serum bicarbonate / pH - Normal / pH 7.4
- Serum ketones - 0
- Mortality - 30% (thromboses)
- Subsequent course - Diet/tablet controlled

Is this representing DKA or HHS?

HHS
HHS - Case study
- 78y old woman previously well. Two months polyuria & polydipsia, tiredness.
- Had been drinking Lucozade to feel better. Had noted urine offensive to smell for several days and was experiencing dysuria.
- Found collapsed by daughter in afternoon. Brought by ambulance to A&E.
- What examination and investigations?

- Drowsy, pale, pyrexial 38.5C, BP 80/55
- Blood Sugar 57mmol/l - high
- Urine ketones 0, +++ wbc, ++ nitrites, protein +++, blood +++
- pH 7.44, pCO2 5.8, HC03 23, Lactate 1.4
- Plasma hydroxybutyrate 0.5
- Na144, K3.8, Urea35.2, Creat 160,
- Hb 14.8g/dl, wbc 18.9
- CXR – normal ECG normal
- Osmolality: (144+3.8) x2 +35.2 +57 = 387.6 (normal 280-300mosm/kg)
Calculating Osmolality:
- Add … and … together ions, times by …, add … and blood … levels after.
- Anything above 320 = consistent with …
- Add sodium and potassium together, times by 2, add urea and blood sugar levels after.
- Anything above 320 = consistent with HSS
HSS - Management
- Correct the prefound …
- Confirm diagnosis and check for precipitating causes
- Rehydrate & monitor fluid balance
- Iv fluids - … with added potassium
- Consider urinary …
- Lower glucose (once glucose not improving with fluids)
- Intravenous insulin – fixed rate … Unit/kg/hr
- Monitor …
- Potassium (and sodium)
- Prevent …
- Treatment low molecular weight heparin
- Patients are often … and … ill.
- Correct the prefound dehydration
- Confirm diagnosis and check for precipitating causes
- Rehydrate & monitor fluid balance
- Iv fluids - saline with added potassium
- Consider urinary catheter
- Lower glucose (once glucose not improving with fluids)
- Intravenous insulin – fixed rate 0.05Unit/kg/hr
- Monitor electrolytes
- Potassium (and sodium)
- Prevent clots
- Treatment low molecular weight heparin
- Patients are often elderly and severely ill.
Hypoglycaemia
- Causes:
- Too … food or … a meal; too much … or diabetes pills; more … than usual
- Onset:
- Often …; may pass out if untreated
- Causes:
- Too little food or skip a meal; too much insulin or diabetes pills; more active than usual
- Onset:
- Often sudden; may pass out if untreated

Hypoglycaemia - Definition and Classification
- Hypoglycaemia is a biochemical term and exists when blood sugar < …mmol/l but is often used to describe a … state. The clinical syndrome associated with hypoglycaemia develops as the nervous system becomes glucose deficient or ‘…’. It can be classified:
- Asymptomatic
- Whilst …
- Whilst …
- Mild symptomatic (patient can treat …)
- Severe symptomatic (help needed by …)
- Coma and …
- Hypoglycaemia is a biochemical term and exists when blood sugar < 4mmol/l but is often used to describe a clinical state. The clinical syndrome associated with hypoglycaemia develops as the nervous system becomes glucose deficient or ‘neuroglycopaenic’. It can be classified:
- Asymptomatic
- Whilst Awake
- Whilst sleeping
- Mild symptomatic (patient can treat himself)
- Severe symptomatic (help needed by third party)
- Coma and convulsions
Hypoglycaemia - Symptoms
- … symptoms – … activation
- Sweating, feeling hot
- Trembling or shakiness
- Anxiety
- Palpitations
- … symptoms
- Dizziness, light-headedness
- Tiredness
- Hunger, nausea
- Headache
- Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism
- Coma and convulsions, hemiplegia
-
Autonomic – sympathomedullary activation
- Sweating, feeling hot
- Trembling or shakiness
- Anxiety
- Palpitations
- Neuroglycopenic
- Dizziness, light-headedness
- Tiredness
- Hunger, nausea
- Headache
- Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism
- Coma and convulsions, hemiplegia
Hypoglycaemia - Symptoms
-
Autonomic symptoms – sympathomedullary activation
- What are the 4 symptoms?
-
Neuroglycopenic symptoms
- What are the 6 symptoms?
-
Autonomic symptoms – sympathomedullary activation
- Sweating, feeling hot
- Trembling or shakiness
- Anxiety
- Palpitations
-
Neuroglycopenic symptoms
- Dizziness, light-headedness
- Tiredness
- Hunger, nausea
- Headache
- Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism
- Coma and convulsions, hemiplegia
Hypoglycaemia - Causes
- Insulin
- Inappropriately … doses
- Not eating, or insufficient …
- S… (med for type 2 diabetes)
- Insulin
- Inappropriately excessive doses
- Not eating, or insufficient carbohydrate
- Sulfonylureas
Hypoglycaemia - counter-regulation
- Glucagon, adrenaline, cortisol and GH all have ‘anti-… effects’
- Glucagon stimulates glycogenolysis and gluconeogenesis and is probably … response
- Adrenaline increases gl…
- GH and cortisol limit glucose … in peripheral tissues, but this effect takes … so of little benefit acutely
- … nerves may also directly activate hepatic glycogenolysis and stimulate … secretion
- Glucagon, adrenaline, cortisol and GH all have ‘anti-insulin effects’
- Glucagon stimulates glycogenolysis and gluconeogenesis and is probably primary response
- Adrenaline increases glycogenolysis
- GH and cortisol limit glucose disposal in peripheral tissues, but this effect takes several hours so of little benefit acutely
- Sympathetic nerves may also directly activate hepatic glycogenolysis and stimulate glucagon secretion
Hypoglycaemia - Treatment
- Minor episodes
- …g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something ‘…’ to eat
- Glucose …
- Hypoglycaemic …
- im or iv Glucagon 1mg
- iv … 25g (150ml 10% glucose)
- Minor episodes
- 20g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something ‘starchy’ to eat
- Glucose gels
- Hypoglycaemic coma
- im or iv Glucagon 1mg
- iv dextrose 25g (150ml 10% glucose)

Diabetic Emergencies - Summary
- DKA
- Insulin … > k… > ac…
- Treat with …, fluids and …
- HSS
- Relative insulin deficiency > …glycaemia > profound …
- Treat with fluids & insulin
- Hypo
- Too much …
- Treat with …
- DKA
- Insulin deficiency > ketosis > acidosis
- Treat with insulin, fluids and potassium
- HSS
- Relative insulin deficiency > hyperglycaemia > profound dehydration
- Treat with fluids… insulin
- Hypo
- Too much insulin
- Treat with glucose