Acute complications of diabetes Flashcards
What occurs in the autonomic system during hypoglycaemia (<4)?
Adrenal glands produce adrenaline and pancreas produces glucagon in an attempt to release liver glucose stores.
What are the first signs of hypoglycaemia?
Shaking
Blurred vision
Headache
Hunger
Anxiety
Sweating
At what glucose level would someone experience neuroglycopaenic symptoms?
<2.8
What do neuroglycopaenic symptoms indicate?
That the brain is getting insufficient supply of glucose.
What are the neuroglycopaenic symptoms?
Slurred speech
Slower reactions
Seizures
Dizziness
Confusion
Coma
What causes hypoglycaemic unawareness?
Neuroglycopenia occurs before autonomic symptoms.
Reduced sympathetic activation due to cellular adaption from recurrent hypoglycaemia. This leads to hypoglycaemic associated autonomic failure.
Body failures to recognise the need to correct glucose levels.
What is the immediate treatment of hypoglycaemia?
20g quick/rapid acting carbs
Once blood glucose is above 4mmol/L, what type of carbs should be given?
Slow release carbs 10-20g
How long does a glucagon s/c or IM injection take to increase blood glucose levels?
10 minutes
In what conditions would glucagon injections be less effective in?
Chronically malnourishes
Depleted glycogen stores
Severe liver disease
What % of dextrose is recommended for hypos?
20%
How much IV dextrose is given during a hypo?
100mls over 10/15mins.
Why should insulin never be omitted in a T1DM?
Increases their risk of DKA
What is the diagnosis criteria for DKA?
CBG >11mmol/L
Ketones >3 (Capillary) or >2+ (Urine)
Acidosis - HCO3- <15 or pH <7.3
Why is it important to be aware of the effects of early intervention in DKA?
Early intervention to correct glucose levels could show a normal blood glucose levels, but would not correct ketones or acidosis therefore patient may still have DKA.
During insulin deficiency, what happens in the liver?
The liver switches to making glucose by increasing gluconeogenesis (synthesise glucose) + glycogenolysis (Glycogen to glucose). The reduces glycogenesis (formation of glycogen).
During insulin deficiency, what happens in fatty tissue?
Lipolysis increases to generate fatty acids that can be oxidised in the TCA cycle.
Adipogenesis decreases.
During insulin deficiency, what happens in skeletal muscle?
Increase in glycogenolysis (using glycogen reserves).
Increased in lipolysis - to generate fatty acids.
Decrease in glycogenesis and protein synthesis - catabolised into amino acids that can be utilised by the liver in further gluconeogenesis.
Which regulatory hormones are increased in insulin deficiency?
Cortisol
GH
Catecholamines
Glucagon
How does insulin deficiency cause shock and CV collapse?
Insulin deficiency –> Hyperglycaemia –> Glycosuria –> Dehydration (+Electrolyte loss) –> Renal failure –> Shock –> CV collapse.
How does insulin deficiency cause acidosis and CV collapse?
Insulin deficiency –> Lipolysis –> Increase in FFA’s –> Ketones –> Acidosis –> CV collapse
What are the common signs of DKA?
Polyuria
Polydipsia
Nausea
Abdo pain
Ketone breath
Kussmaul breathing
Lethargy
Confusion
Coma
Which ketone body in DKA increases 10 fold?
3-beta-hydroxybutyrate
Which medications can cause DKA?
Seroids
How does the body compensate in acidosis?
Intracellular buffering - H+/K+ exchange
Respiratory - hyperventilation. H+ stimulates respiratory centres + can breathe off CO2,
Renal excretion of H+
Which electrolytes can be affected by renal secretion of H+ during acidosis?
K+ + Na+ loss = dehydration
At which GCS would ITU be involved in DKA?
<12
Which levels of pH and Bicarb would indicate a severe acidosis?
pH <7.1
Bicarb <5
During DKA, when would IV K+ be administered?
If K+ <5.5 - 40mmol/L
If K+ <3.5 - may need additional K+
How is DKA treated?
Fixed rate IV insulin - 0.1unit/kg/hr
50 units of Actrapid in 50ml N/Saline
Which is the fluid management for someone in DKA?
For the treatment of DKA, how quickly should ketones and glucose reduce by?
Ketones 0.5mmol/L/hr
Glucose 3mmol/L/hr
How quickly should bicarb rise by during the treatment of DKA?
3mmol/L/hr
Which fluid is given in addition to N/Saline + K+ during DKA treatment?
IV Dextrose
When should Dextrose be given during DKA treatment and at what percentage?
10% dextrose when CBG’s <14mmol/L
125ml per hour
During DKA, if a patient is not eating and drinking, what type of insulin replacement would be most appropriate?
Variable rate insulin regime (sliding scale)
If ketonaemia and acidosis is not resolving with the treatment of DKA, which medication should be increased and by how much?
Insulin = by 1unit per hour
What are the complications of DKA treatment?
Cerebral oedema
Hypo/hyperkalaemia
Hypoglycaemia
Pulmonary oedema
What is the diagnostic criteria for HHS?
Hypovolaemia
Hyperglycaemia >30mmol/L (Without significant hyperketonaemia)
Osmolarity >320mosmol/kg
What are clinical features of HHS?
Insidious onset
Polyuria
Polydipsia
Muscle weakness
Blurred vision
Hallucinations
Coma
Clinical signs of dehydration
Which are the precipitants of HHS?
Infection
MI
High dose steroids
Cocaine
How is HHS treated?
Replace fluid loss
Correct electrolytes and osmolarity
Reduce glucose
Treat precipitant
Which fluid is given in HHS?
N/Saline
How much N/Saline is given during the treatment of HHS?
3-6L +ve balance by 12 hours
During the treatment of HHS, Na+ should not exceed a reduction of how much in 24 hours and why?
> 10mmol - risk of cerebral oedema
During the treatment of HHS, glucose should not exceed a reduction of how much in 24 hours?
5mmol/L
Is IV Insulin given during the treatment of HHS?
No - only if glucose doesn’t reduce or if ketones are present.
What are some complications of HHS treatment?
Fluid overload
Cerebral oedema
Central pontine myelinosis
How is osmolarity calculated?
2xNa+ + Urea + glucose
What is the normal osmolarity range?
275-295mmol/kg
Does HHS or DKA have a higher mortality rate?
HHS
