Acute Complications of Diabetes

Question 1

3 main acute complications of diabetes

Answer 1

Diabetic ketoacidosis
Hyperglycemic hyperosmolar syndrome
Hypoglycemia

Question 2

Diabetic ketoacidosis (what is it, and what 4 things is it characterized by)

Answer 2

Metabolic decompensation resulting from an absolute (or close to) insulin deficiency
Usually in T1D
Characterized by: hyperglycemia, metabolic acidosis, ketones in blood, volume depletion

Question 3

Clinical features of DKA

Answer 3

Prodrome (1-2 days of polydypsia/uria (from hyperglycemia), weakness, nausea, vomiting, abdo pain)
Volume depletion
Tachypnea
Acetone (fruity) breath
Myalgia (from anaerobic metabolism)
Normal temp or hypothermia (bad sign)

Question 4

Kussmaul breathing

Answer 4

Rapid deep inspirations

Trying to compensate for metabolic acidosis

Question 5

4 precipitating conditions for DKA

Answer 5

Acute illness (infection, stroke, MI, pancreatitis)
New onset diabetes
Insulin under-dosing
Drugs (alcohol, cocaine, lithium)

Question 6

Mechanism of DKA

Answer 6

Absolute insulin deficiency
Loss of glucagon suppression
Excess glucagon results in increased gluconeogenesis and ketogenesis

Question 7

Triad of DKA

Answer 7

Hyperglycemia
Metabolic acidosis
Ketosis

Question 8

Anion gap

Answer 8

Positive ions (Na) - negative ions (Cl and bicarb)
Normal is 10-14

Question 9

How is the anion gap affected in DKA?

Answer 9

Wider! More than 16

Because you have less bicarb (buffering the acid)

Question 10

3 things we want to treat first in DKA

Answer 10

Volume
Hyperkalemia
Ketogenesis

Question 11

Management of DKA

Answer 11

Volume repletion with normal saline
Stop ketogenesis (give insulin)
K repletion (slowly)
Normalize glucose
Treat precipitating condition
Avoid complications

Question 12

What is the biggest risk complication of pediatric DKA?

Answer 12

Cerebral edema

Question 13

Cushing’s triad

Answer 13

A sign of increased intracranial pressure

Hypertension, bradycardia, irregular respiration

Question 14

Management of suspected cerebral edema

Answer 14

Don’t wait!!
Elevate the head, reduce IV fluids
Give mannitol (osmotically active - decreases blood viscosity and improves cerebral blood flow)
Give 3% hypertonic saline (instead of or along with mannitol - lowers ICP, increases intravascular volume and MAP)

Question 15

Hyperglycemic hyperosmolar state (what is it, what is it characterized by)

Answer 15

Metabolic decompensation resulting from relative insulin deficiency and severe hyperglycemia and volume depletion
Usually T2D
Characterized by: hyperosmolality, hyperglycemia, volume depletion

Question 16

Clinical features of HHS

Answer 16

Often elderly
Prodrome (polydipsia/uria, weakness, confusion, lethargy)
Poor fluid intake
Volume depletion
Hypothermia

Question 17

Precipitating conditions of HHS

Answer 17

Acute illness (infection, MI, stroke, pancreatitis, PE, bowel obstruction, renal failure, subdural hematoma, burns, heat stroke)
Drugs (Ca channel blockers, phenytoin, thiazides)

Question 18

Normal plasma osmolality value

Answer 18

285-295 mosm/L

Question 19

Management of HHS

Answer 19

Volume repletion (1/2 saline)
Normalize glucose (insulin)
K repletion
Treat precipitating condition
Monitor

Question 20

pH and glucose in DKA and HHS

Answer 20

DKA: severe acidosis, moderate hyperglycemia
HHS: mild acidosis/normal pH, severe hyperglycemia
Normal is pH 7.25 to 7.30

Question 21

Clinical features of hypoglycemia

Answer 21

Autonomic (E/NE): sweating, tachycardia, tremor, hunger, anxiety, warm, nausea
Neuroglycopenic (CNS): dizzy, weak, blurred vision, drowsiness, confusion, seizure/coma

Question 22

Risk factors for hypoglycemia

Answer 22

Elderly, cognitive dysfunction/dementia
Liver/kidney dysfunction
Adrenal insufficiency
Lack of diabetes education
Alcohol consumption
Exercise
Food insecurity, missed/delayed meals
Certain medications

Question 23

Treatment of hypoglycemia

Answer 23

Home glucagon injection kits
Strict avoidance of hypoglycemia
Rapid acting glucose