complications of diabetes Flashcards
who/when can diabetic ketoaacidosis occur
those with T1DM or the 1st presentation of it
- rare + only under extreme stress does it affect T2DM
precipitating factors
- infection
- missed insulin
- myocardial infarction
features of DKA
abdo pain
polyuria, polydipsia, dehydration
acetone breath - “peardrops” smell
Kussmaul respiration (deep hyperventilation)
diagnostic criteria of DKA
glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
bicarbonate < 15 mmol/l
ketones > 3 mmol/l or urine ketones ++ on dipstick
key points of DKA management
- fluid replacement - isotonic saline
- insulin
- once BM <14, infusion of 10% dextrose should be started in addition to the 0.9% sodium chloride regime - correct electrolyte disturbances
long acting insulin should be continued, short acting should be STOPPED
management of electrolye disturbances in DKA
serum potassium often high despite total body potassium being low
- this often falls quickly following treatment with insulin resulting in hypOkalaemia
potassium may therefore need to be added to the replacement fluids
if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required
who needs slower fluid resus in DKA? Why?
young adults (18-25yrs)
–>greater risk of cerebral oedema
DKA resolution definition
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
complications of DKA
- gastric stasis
- VTE
- arrythmias - 2nd to potassium
- iatrogenic due to poor fluid therapy - cerebral oedema, hypokalaemia
acute resp distress syndrome
AKI
Hyperosmolar hyperglycaemic state
hyperglycaemia results in osmotic diuresis, severe dehydration + electrolyte deficiencies
typically = elderly with T2DM
med emergency + 20% mortality
pathophysio of DKA
caused by uncontrolled lipolysis (not proteolysis) which results in an excess of free fatty acids that are ultimately converted to ketone bodies
pathophysio of Hyperosmolar hyperglycaemic state
hyperglycaemia → ↑ serum osmolality → osmotic diuresis → severe volume depletion
Hyperosmolar hyperglycaemic state precipitating factors
intercurrent illness
dementia
sedative drugs
differences between DKA + HHS
DKA
- T1DM
- presents within hours
- ketones ++
- rapid breathing, N+V
HHS
- T2DM
- comes on over days (metabolic disturbances more extreme)
- minimal/no ketones
- confusion, lethargy
features of HHS
- comes on over days
- lethargy
- dehydrated, polyuria/dipsia
- N+V
- confused
- blood hyperviscous - MI, stroke
diagnostic criteria HHS
no precise criteria but-
- hypovolaemia
- hypergkycaemia >30
- raised serum osmolarity >320
- no significant ketones <3
- no significant acidosis >7.3
management of HHS
fluid replacement
- IV 0.9% sodium chloride
- monitor potass, add depending on level
insulin - should NOT be given unless blood glucose stops falling while giving IV fluids
VTE prophylaxis
complications of HHS
vascular complications due to hyperviscosity of blood
- MI
- Stroke
(due to extreme dehydration)
causes of hypoglycaemia
- insulinoma (increased ratio of proinsulin to insulin)
- self-admin of insulin/sulphonylureas
- liver failure
- addisons
- alcohol
- nesidioblastosis - beta cell hyperplasia
why can alcohol cause a hypo
causes exaggerated insulin secretion
mechanism is thought to be due to the effect of alcohol on the pancreatic microcirculation → redistribution of pancreatic blood flow from the exocrine into the endocrine parts → increased insulin secretion
hypoglycaemia presentation based on blood glucose levels
<3.3 autonomic sx (due to release of glucagon + adrenaline)
- sweating, shaking
- anxiety, nausea
<2.8 neuroglycopenic sx (due to low glucose supply to brain)
- weakness, vision changes
- confusion, dizziness
severe/rarely -
- convulsion
- coma
hypoglycaemia investigations
if cause not clear, a combo of serum insulim + c-peptide levels can be measured
(insulin + C-peptide are release in equimolar amounts from pancreas –> C-peptide is a marker of endogenous insulin production)
what might high insulin levels + high C-peptide levels tell you in hypoglycaemia
endogenous insulin production
causes
- insulinoma
- sulfonylurea use/abuse
what might high insulin levels + low C-peptide levels tell you in hypoglycaemia
exogenous insulin administration
- exogenous insulin overdose
- factitious disorder
what might low insulin levels + low C-peptide levels tell you in hypoglycaemia
non-insulin related cause
- alcohol induced
- critical illness - sepsis, adrenal insufficiency, growth hormone deficiency
- fasting/starving
management of hypoglycaemia in the community
- oral glucose 10-20g - liquid, gel or tab
Px may be given “hypokit” contains syringe + vial of glucagon IM or SC
management of hypoglycaemia in hospital setting
if patient alert -> quick acting carbohydrate/glucogel
unconscious/unable to swallow -> SC / IM glucagon
or IV 20% glucose
