Acute Complications of Diabetes Mellitus Flashcards
What are the diabetic emergencies?
- Hypoglycaemia
- Diabetic ketoacidosis= T1
- Hyperosmolar Hyperglycaemic Syndrome (HONK)= T2
- Lactic acidosis (metformin)
Describe hypoglycaemia
- Commonest diabetic emergency
- Most episodes treated at home
- Average person with Type 1 DM will experience 1000s of episodes of mild hypoglycaemia
- 1-2 episodes of severe hypoglycaemia every year (very variable)
- Severe = need for external assistance
What are the common causes of hypoglycaemia?
-Patient error- =too much insulin =too little carbohydrate =Missed/late meal =Exercise -Alcohol -(Same applies for patients on sulphonyreas eg gliclazide, glipizide= stimulates body to make insulin)
What are the mechanisms of sulfonylureas?
- Encourage beta cells to produce more insulin, close potassium ATPase channel without glucose
- Glucose entering cell by GLUT2, broken down by glycolysis, mitochondria use to make ATP, powers K-ATPase channel, depolarisation, influx of calcium, triggers release of insulin
What are the less common causes of hypoglycaemia?
- Decreased insulin requirements e.g. weight loss (fat resistant to insulin)
- Liver disease, alcohol (glucagon on liver activity decreases)
-Conditions associated with T1DM (autoimmune)
=Coeliac disease (less absorption of carbohydrate)
=Addison’s disease (cortisol important in counter regulation)
=Hypothyroidism (slows basal metabolic rate)
=(Hypopituitarism)
-Complications of diabetes
=Autonomic neuropathy (damage to nerves that control automatic processes, gastroparesis or rapid transit time in bowel= less absorption)
=Injection sites/lipohypertrophy
=Renal failure (excretes insulin less efficiently)
=Counterregulatory failure
Describe counter regulation of hypoglycaemia
SHORT TERM (drops below 4)
-Glucagon= alpha cells in pancreas, balances insulin (when blood sugar is low)
-Epinephrine/ adrenaline= adrenal gland
=heart racing
=sweaty
=shaky
=EEH impaired, brain not working so well (3 mmol)
=Cognitive function decline (2,8)
=impaired consciousness, coma, death/ severe neuroglycopenia (less than 1.5)
LONGER TERM
- Cortisol= adrenal gland, protective hormone in prolonged hypoglycaemia
- GH= pituitary
What are the symptoms of hypoglycaemia?
-Autonomic =Sweating =Shaking =Palpitations =Hunger -Neuroglycopenic =Confusion =Irritable =Anxious =Drowsiness =Blurry vision =Difficulty speaking =Odd behaviour =Incoordination -Malaise =Nausea =Headache =Weakness/ fatigue
How to symptoms of hypoglycaemia change with age and time?
- These are most common symptoms in young adults
- Children often manifest behavioural change
- Elderly can have neurological symptoms (eg mimic stroke)
- Symptoms are idiosyncratic and may change with time
Why might symptoms of hypoglycaemia change over time?
-Counter-regulatory hormones change over time
=lost ability to produce as a result of hypoglycaemia
=Glucagon response first
=Adrenaline
=Cortisol
=Growth Hormone
Therefore Impaired Awareness of Hypoglycaemic (gradually at lower blood sugar levels therefore reduces ability to help themselves)
How is impaired awareness of hypoglycaemia a cycle?
-Hypoglycaemia
=Impaired physiological responses to hypoglycaemia (less response, less warnings)
=Reduced awareness of hypoglycaemia
=Increased vulnerability to further episodes of hypoglycaemia
How do we diagnose hypoglycaemia?
-Whipple’s triad: 2 out of 3 of-
=Typical symptoms
=Biochemical confirmation (no agreed cut-off, blood glucose level- usually 4 mmol/L, above level of counter-regulatory hormones and safety buffer)
=Symptoms resolve with carbohydrate
-Remember ‘atypical’ presentations esp in elderly
=Hemiparesis
-In theory, confirm with laboratory blood glucose – but don’t delay treatment
How is hypoglycaemia managed?
- If alert, give sweet drink or dextrose tablet
- If not alert give 20% dextrose iv (or Hypostop, Polycal gels, buccal)= may aspirate into lungs if oral
- If can’t get iv access, give 1mg intramuscular glucagon plus sweet drink (not effective in alcoholic hypo)
- Follow-up rapid acting carbs with slow release carbs (toast, digestive biscuits)
- 10% glucose infusion if long-acting insulin or SU.
- If recovery not rapid (5-10 minutes), consider other cause.
- Full cognitive recovery can lag by 45 mins (driving)
How has sugar tax affected hypoglycaemia management?
- Glucose content of carbonated soft drinks is being reduced
- This is as a result of a levy on sugary drinks
- Some companies have publicised the change – others will not
=We no longer routinely recommend drinks like Lucozade to treat hypos
=Tea with sugar or fruit juice still fine
Describe the aftercare of hypoglycaemia
-Follow-up glucagon/ dextrose with a starchy snack
-Patients presenting to hospital with hypo are
=Older
=Live alone
=Co-morbidity
=Sulfonylurea therapy
-Discharge if make full recovery and responsible adult at home – but not if sulfonylurea-induced
-Inform the diabetes team
-Close monitoring of blood glucose for next 72 hours
-Was there an obvious remedial cause?
-If not, cut right back on insulin doses
Describe continuous subcutaneous glucose sensors
- Worn in skin
- Bluetooth readings to device on belt
- Continuous view of blood sugars
