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Year 3 Medicine - Endocrinology Block > Acute complications of diabetes > Flashcards

Acute complications of diabetes Flashcards

1
Q

Define hyperglycaemic hyperosmolar state.

A

A diabetes emergency characterised by the triad of
1. Hyopovolaemia
2. Marked hyperglycaemia of more than 30 mmol/L without significant hyperketonaemia <3 mmol/L) or acidosis (pH > 7.3 and HCO3 >15 mmol/L)
3 osmolality of > 320 mosmol/kg

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2
Q

What is the mean age of presentation of hyperglycaemic hyperosmolar state?

A

60 years old

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3
Q

What can cause hyperglycaemic hyperosmolar state?

A
  • Undiagnosed Type II diabetes
  • infection
  • MI/CVA
  • drugs such as glucocorticosteroids, beta blockers, thiazide diuretics
  • non-compliance with insulin or hypoglycaemic medication
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4
Q

Describe the pathophysiology of hyperglycaemic hyperosmolar state

A

Develops over many days (DKA rapidly)

Prolonged hyperglycaemia from insulin resistance causes osmotic diuresis with renal sodium and potassium loss.

This causes ECF depletion and dehydration and raised serum osmolality

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5
Q

what are the symptoms and signs of HHS?

A

polydipsia and polyuria

impaired cognitive function

tachycardia

hypertension

seizures

focal signs of thrombosis

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6
Q

Which investigations should you request in someone with hyperglycaemic hyperosmolar state?

A
  • Capillary blood glucose
  • Plasma glucose
  • Renal function
  • Serum osmolality calculated using (2(Na+) + glucose + urea)
  • venous blood gas (with lactate) to exclude sitnidicant acidosis
  • blood ketones to exclude ketonaemua
  • FBC
  • CRP
  • septic screen if indextion suspected (blood and urine cultures, Chest Xray)
  • ECG - tachycardia from severe dehydration or ischaemia in acute coronary syndrome
  • Troponin level - if cardiac ischamia suspected cause
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7
Q

what are the three main aims of treatment of HHS?

A
  1. treat underlying cause of HHS 2. gradually normalise osmolality and glucose
  2. replace fluid and electrolyte losses
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8
Q

Name the management of HHS.

A
  1. 0.9% saline as fluid replacement
  2. IV fluids - aim to creat 3-6L balance within first hour of hours, with remaining fluid losses replaced over next 12h (tailored according to patient - caution needed in elderly as can caus heart failure) - also caution as too rapid replacement is harmful
  3. Replace potassium only if needed
  4. Only use IV insukin if plasma glucose doesn’t fall following treatment of if significant ketonaemua - if so use rate 0.05 units/kg/hour
  5. Treat underlying cause eg infection
  6. Freq assessment for complications eg fluid overload
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9
Q

What are the risks of HHS?

A

Mortality - 15-20%

Morbidity - complications eg vascular disease eg MI, stroke, also seziures and cerebral oedema and central pontine myelinolytis

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10
Q

Define ketoacidosis.

A

Triad of

  1. Hyperglycaemia (>11 mmol/L)
  2. Ketonaemia ( > 3mmol/L)
  3. Acidosis (pH <7.3 +/- HCP3 < 15 mmol/L)
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11
Q

Describe the pathophysiology of DKA

A
  1. A relative or absolute insulin deficiency causes impaired glucose uptake in peripheral tissues
  2. . Increased gluconeogenesis and glycogenolysis in liver worsens glycaemia
  3. Counter regulatory hormone secretion eg cortisol, glucagon and catecholamines along with insulin deficiency causes release of free fatty acids into circulation as a result of lipolysis in adipose tissue.
  4. FFS undergo oxidation in liver to form ketone bodies (B hydroxybutyrate, acetoacetate and acetone) and cause ketoaemia.
  5. Ketone bodies are weakly acidic so cause increased plasma hydrogen ion conc. and metabolic acidosis.
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12
Q

What is the most common cause of DKA?

A

Infection

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13
Q

What are some other causes of DKA?

A
  • new onset T1DM
  • Discontinuation of insulin therapy in type one diabetes
  • insufficient insulin dose/non compliance
  • MI/Cerebrovascular event
  • drugs
  • pancreatitis
  • surgery
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14
Q

What are the symptoms of DKA?

A

DKA devlops rapidly over 24hr:

  • polyuria
  • polydipsia
  • lethargy
  • vomiting
  • abdominal pain
  • dehydration
  • altered mental state
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15
Q

What would you see on examination in a patient with DKA?

A
  • Dry mucous membranes
  • Smell of ketones
  • tachycardia
  • hypotension
  • Kussmaul breathing
  • signs if cause eg infection
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16
Q

What investigations should you request when you suspect a patient has diabetic ketoacidosis?

A
  • Bedside meters to measure capillary glucose and ketones - if not available urine dipstick to measure ketone in urine
  • Venous blood sample to measure pH and bicarbonate
  • Initial raised capillary glucose value must be confirmed with lab assessment of plasma glucose from venous blood sample
  • FBC, renal function
  • Septic screen if infection (blood and urine cultures, chest Xray)
  • ECG - tachycardia from dehydration or arrythmia from electrolyte disturbance.
17
Q

What are the main aims of management in DKA?

A
  1. Restoration of circulatory volume
  2. Ketone clearance
  3. Correction of electrolyte disturbance
18
Q

How should fluid be replaced in DKA?

A

IV crystalloid
Caution in young adults, elderly or in cardiac/renal failure

Normal 0.9% saline
1L in 1st hour, 1L in 2 hours, 1L over 2 hours, 1L in 4 hours, 1L over 4h, 1L in 8 hours.

Add 10% dextrose 125ml/hr when blood glucose < 14mmol/L

Potassium replacement as needed

19
Q

How is insulin replaced in DKA?

A

Fixed rate intravenous infusion (FRII) based on body weight

Rate of 0.1kg body weight/hour until DKA fully resolved

If patient is on subcutaneous long acting analogue or human insulin continue these throughout treatment

20
Q

Why do you need to carefully monitor electrolytes in treatment of DKA? When do you need to measure electrolytes in DKA?

A

IV insulin can cause hypokalaemia.

Every 4 hours

21
Q

How often do you need to check capillary glucose and ketones in DKA?

A

Check hourly until complete resolution ( ketones <0.6mmol/L and venous pH >7.3)

22
Q

What do you need to do when DKA is resolved?

A

Convert patient to regular subcutaneous insulin regimen.

Involve diabetes team to educate the patient esp. in “sick day rules” (see safe insulin prescribing) to prevent recurrence

23
Q

How does illness percipitate DKA? What do you need to warn patients about when they’re on insulin therapy and have infection?

A

During illness, the body makes more cortisol (which increases blood
glucose levels and hence antagonises the action of insulin) • So insulin requirements increase during infection

• Patients should monitor their blood glucose even more closely during
periods of illness and increase insulin doses

24
Q

What is Kussmaul breathing?

A

Feature of DKA
o Rapid, deep inspiration
o Due to the decreased pH stimulating the respiratory centre

Year 3 Medicine - Endocrinology Block (16 decks)

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