Chempath - Hyper and Hypoglycaemia

Question 1

General causes of hyperglycaemia

Answer 1

Increased insulin resistance

Absolut insulin deficiency

Question 2

Diagnosis DM

Answer 2

Either typical symptoms plus one of Fasting glucose >7, Oral glucose tolerance test >11.1 or random glucose >11.1

OR made without symptoms via 2 of the above tests.

OR HbA1c >6.5% (48mmol/mol)

Question 3

Values for impaired glucose tolerance and impaired fasting glucose

Answer 3

IGT- Random or oral glucose tolerance test >7.8 but <11.1

IFG - fasting glucose >6.1 but <7.0

Question 4

Hyperosmolar hyperglycaemic state (HHS) Criteria

Answer 4

T2DM

pH > 7.3
Osmolarity > 320mOsm
Blood Glucose > 30mM

Clinically: present similarly to DKA, acutely unwell with confusion and clinical dehydration. May lose unto 20% of body weight in fluid losses.

Question 5

HHS Rx

Answer 5

Fluid replacement – Aggressive, can usually use normal saline +/- potassium. Aim +3-6L by 12h depending on weight and extent of dehydration. Aiming to reduce Glucose no more than 5mM/h and Na+ by 10mM/24h.

Monitoring - Serial U+Es and glucose readings

Potassium - Supplementation only needed if K+ between 3.5-5.5

Insulin - Can be used if glucose no longer falling with fluids alone. Use 0.05u/Kg/hr fixed dose.

Monitor pressure areas – high risk of ulceration

Monitor neuro obs

Question 6

DKA Criteria

Answer 6

pH < 7.3
Plasma Glucose >11mM
Blood Ketones>3mM (2+ in urine)

Clinically:
Medical emergency, presenting with collapse/confusion, a dehydrated/shocked patient, may be associated with kussmaul breathing, abdominal pain, nausea, vomiting. Precipitants include: Infection, surgery, missed insulin doses, trauma (hypercortisolism increases insulin resistance). Patients lose up to 10% of bodyweight in water.

Question 7

DKA Rx

Answer 7

Identify and treat cause/trigger

Bloods (inc VBG unless concerns over respiratory function where ABG would be more appropriate), ECG, spot ketones + glucose.

Fluids - These must be started first. Replacement of deficit + maintenance over 24h. Front load replacement and taper off gradually. N. Saline is fluid of choice. If potassium low add in 40mM KCl (n.b. you cannot administer
>10mM/h K+ outside of ITU). Supplement if <5.5 even if bloods seem fine as there will be a big shift when you start insulin (exchange with H+).

Insulin - Started after fluids, ensure K+ not <3.5, 0.1u/kg/h fixed dose regimen. DO NOT STOP background basal insulin – the state of deficiency the patient is in is in the context of this being present. Once BM drops to <15, give 10% dextrose to prevent rebound hypoglycaemia.

Early senior review +/- ITU involvement

Monitoring- Aiming to reduce Ketones by 0.5/h and glucose by around 3/h. Hourly VBG for K+ and HCO3- - aim to keep serum K+ >4. Catheterisation is useful, aiming O/P >0.5ml/kg/hr.

Resolution is when ketones <0.6 and pH >7.3

Question 8

TD1M HLA associations

Answer 8

HLA DR3 and DR4

Question 9

What happens to acid-base balance in a metformin overdose?

Answer 9

Lactic acidosis (metabolic acidosis with high anion gap)

Question 10

Causes of hyperinsulinaemic hypoglycaemia with reduced C-peptide

Answer 10

Exogenous insulin: Poor patient understandin g of therapy Inappropriate insulin delivery method for patient [e.g. unable to appropriately titrate dose/see units on insulin pen] Intentional inappropriate use (?Psychiatric concerns)

Question 11

Causes of hyperinsulinaemic hypoglycaemia with appropriate C-peptide

Answer 11

Endogenous cause:
Insulinoma (requires -ve sulphonylurea screen- C-pep increased by sulphonylureas)
Quinine
Pentamidine (for too, PCP, leishmania)
Islet cell hyperplasia - infant of diabetic mother
Beckwith Weide-Mann syndrome
Nesidioblastosis

Question 12

Hypoinsulinaemic hypoglycaemia, adults

Answer 12

Fasting
Strenuous exercise
Critical illness
Endo def (hypo-it, adrenal failure)
Liver failure
Anorexia nervosa

Question 13

Hypoinsulinaemic hypoglycaemia, neonates - ketones present

Answer 13

Premature
IUGR/SGA - inadequate glycogen/fat stores
Co-morbidity

Question 14

Hypoinsulinaemic hypoglycaemia, neonates - ketones absent

Answer 14

Inherited metabolic disorder

Question 15

Non-islet cell tumours

Answer 15

↓ Glucose, ↓ Insulin, ↓ C-peptide, ↓FFA and ↓ Ketones

Tumours that cause a paraneoplastic syndrome, secreting ‘big IGF-2’, which binds to IGF-1 and Insulin receptors.

Mesenchymal tumours (mesothelioma/fibroblastoma), epithelial tumours (carcinoma).

Question 16

Acute management of hypoglycaemia in adults - alert and orientated

Answer 16

Oral carbs
Rapid acting - juice/sweets
Longer acting - sandwich

Question 17

Acute management of hypoglycaemia in adults - drowsy/confused but swallow intact

Answer 17

Buccal glucose e.g. hypostop/glucogel

Start thinking about IV access

Question 18

Acute management of hypoglycaemia in adults - unconscious but concerned about swallow

Answer 18

IV access

50ml 50% glucose mini-jet or 100mls 20% glucose

Question 19

Acute management of hypoglycaemia in adults - deteriorating/refractory/insulin induced/difficult IV access

Answer 19

Consider IM/SC 1 mg glucagon (mobilises glycogen stores so takes 15-20 mins to work)