Chapter 4: Endocrine and Metabolic Flashcards
What is hypoglycemia?
In DM patients:
Symptoms of hypoglycemia +- CBG
What are the autonomic and neuroglycopenic symptoms of Hypoglycemia?
Autonomic: -Sweating -Hunger -Palpitations -Tachycardia -Tremor -Parasthesia Neuroglycopenic: -Confusion -Irritability -Dizziness -Seizures -LOC -Coma
Causes of hypoGly in a healthy looking patient?
1) Medications
- Insulin/ OHGA overdose and poor oral intake
- Alcohol
- Salicylates
- Recreational drug use(Power one Walnut)
- Non-selective B blocker
2) Intense exercise or missed meal
3) Insulinoma
Causes of hypoGly in an ill-looking pt?
1) Liver Failure
2) Renal failure
3) Severe Infection(Malaria with quinine rx) and sepsis
4) Addisonian crisis
5) Starvation and anorexia
6) Non-islet tumours (mesotheliomas)
What are some RFs of hypoGly?
1) Poor food intake due to sepsis etc
2) Elderly>65
3) DM>10 years
4) ESRF
5) Polypharmacy>10 tabs/day
6) Co-morb>3
7) HbA1c
What invg will you do for this pt with hypoGly?
If DM,
1) Venous blood glucose
2) LFT-for liver dysfunction
3) U/E/Cr-renal failure
4) FBC-for infection
If non-DM,
1) Order 1-2 extra plain tubes of Blood on ice for
- Serum insulin
- Cortisol level
- C-peptide levels
What OHGAs are at high risk of hypoGly?
Sulphonylureas: -Glibenclamide -Tolbutamide -Glimepride Meglitinides: -Repaglinide
Metformin, Rosiglitazone and Acarbose have low to no risk of HypoGly
What is the rx of hypoglycemia?
Depends on the conscious level of pt:
1) If Conscious, oral therapy preferred and hence give carbo-rich drink (Isocal/Ensure)
2) If unconscious, IV dextrose 50% 40ml and flush with normal saline to prevent phlebitis. If no IV access, go for IM/SC glucagon 1mg(H/r, not suitable for use with hypogly secondary to liver failure/sulphonylureas
What are adjunct rx are available for hypoGly?
1) If chronic alcoholic, IV thiamine 100mg
2) Addisonian crisis, IV hydrocortisone 100-200mg
What is the monitoring regime for hypogly?
Check CBG every hourly until it is >10mmol/L on 2 consecutive readings followed by every 2 hours
What is DKA?
DKA is a hyperglycemic and ketonemic state due to an absolute or relative insulin deficiency and an increase in counter reg hormones
What are the potential causes of DKA?
3 Is:
1) Insufficient insulin
2) Infection(UTI, Pneumonia, Skin)
3) Infarction(AMI, CVA, GIT)
How is infection picked up in DKA?
Usually leukocytosis is a poor indicator and hence high level of suspicion must be present for those presenting with fever, no matter how low grade.
What are the initial supportive mgmnt and invg in DKA?
1) Monitored in P1 area with continuous vital signs monitoring along with blood levels of glucose, ketones, potassium and acid-base balance regularly
2) High flow supp O2
3) Set in peripheral IV line
4) Invg to order:
Bloods-FBC, U/E/Cr/Mg/Ca/PO4, Cardiac enzymes(if old), ABG, serum ketones(B-hydroxybutyrate), Blood culture(is septic), serum osmolality
Radio-CXR(if suspecting pneumonia)
Others- Urine(dipstick for infection, ketones), ECG(if old)
5) Urinary catheter to monitor I/O
What is the specific mgmnt for DKA?
1) IV fluid Rx
- If pt in shock, IV Hartmann’s solution 20-30ml/kg over 30 mins, IV antibiotics and ICU
- if pt has severe hypovolemia(dehydrated) without shock, administer 0.9% NaCl 1L/hr and recheck BP
- If pt is not severely dehydrated/hypovolemic, and Na is low, 0.9% NaCl 250-500ml/h. and if the corrected Na is normal/elevated infuse 0.45% NaCl 250-500ml/h over 24hrs.
- Finally switch to 5% Dextrose when serum glucose
