Diabetes

Question 1

Approach to unconscious patient with hypoglycaemia

Answer 1

ABCDE

A- guedel

B-O2

C-pulse, BP,IV access

D-GCS

EFG- glucose

specific- IV glucose and then IM glucagon if glucose less than 4mmol/l recheck every 10 mins

Question 2

Features of ketoacidosis

Answer 2

Hyperglycaemia

ketonuria

acidosis

Question 3

Clinical features of ketoacidosis

Answer 3

Dehydration (high glucose-osmotic diuresis) tachycardia, hypotension (Acidosis is a negative inotrope)

air hunger- kussmaul respiration - acidosis

smell of ketones

vomiting and abdo pain- hyperkalaemia/ acidosis- paralytic ileus, careful of aspiration pneumonia

signs of precipitating cause

Question 4

What happens to potassium in DKA?

Answer 4

Osmotic diuresis takes potassium

dehydration activates RAAS —> further loss

total body K+ low

serum occassionally high or normal

Acidosis—> H+ moved into cells, forcing K+ out

no insulin—> no K+ uptake, until insulin given, where sudden fall

pre-Renal kidney failure- oliguria with failure of K+ excretion

Question 5

Management of DKA in 1st hour

Answer 5

PANICS

Potassium- measure hourly, omit if anuria suspected or >5.5mmol/l

Acidosis- check venous pH and ketones

Normal saline- 500mls over 15 mins if systolic <90mm, otherwise 1 l over 1hr

Insulin- 0.1 units/kg/hr

Catheter and cultures: urine, blood etc

Stomach aspiration if drowsy, ET tube first if no gag reflex

Question 6

Examining the diabetic foot

Answer 6

Inspect-including heels

palpate- cap refill and pulses

light touch- finger, cotton wool or monofilament

avoid pinprick testing

vibration sense

ankle jerks- usually absent

’loss of Protective sensation’

vibrationa and light touch lost first

Joint position, temperature (ethyl chloride spray) if time

Question 7

Stages of diabetic retinopathy

Answer 7

Pre proliferative

​cotton-wool spots

infarcts of unmyelinated nerve cell layer in front of retina

>3 blot haemorrhages

venous bleeding and looping

intra-retinal microbascular abnormalities

Proliferative

New vessels around the disc

peripheral new vessels

new vessels on iris- rubeosis

End-stage

Vitreous haemorrhage from fragile vessels

scarring

tractional retinal detachment

blindness

Question 8

Indications for eye referral

Answer 8

Fall in corrected visual acuity

single cotton wool spot

3 blot haemorrhages

anything macula

new vessels - emergency

Question 9

Implications of microalbuminuria

Answer 9

nephropathy is associated with increased risk of macro vascular disease

increased mortality (macro vascular disease)

‘detected early with screening

usually tested as unremarkable albumin: creatinine ratio

extra attention to risk factory’s is indicated (smoking, lipids, HTN)

ACEi slows progression of impairment

Question 10

what Are the effects of nephron loss in hyperglycaemia

Answer 10

Question 11

How does Hyperglycaemia lead to nephron loss?

Answer 11

Question 12

Plasma glucose ranges

Answer 12

Diabetes symptoms (e.g. polyuria, polydipsia and unexplained weight loss for Type 1) plus:

a random venous plasma glucose concentration ≥ 11.1 mmol/l or

a fasting plasma glucose concentration ≥ 7.0 mmol/l (whole blood ≥ 6.1 mmol/l) or

two hour plasma glucose concentration ≥ 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load. If the fasting random values are not diagnostic the two hour value should be used.

Question 13

HBA1c ranges

Answer 13

Question 14

Give some presenting symptoms of DM

Answer 14

thirst

polyuria

blurred vision

infections- thrush

weight loss/gain

CVA,CVD

foot ulcers

Question 15

How do you screen for diabetic renal disease?

Answer 15

Urinary albumin to creatinine ratio

microalbuminuria- earliest indicator of diabetic nephropathy

ACR>2.5 or 3.5 in men

treatment:

glycaemic controlBP

ACEi/ AngII receptor blocker (renoprotective)

Question 16

Preventative foot care

Answer 16

washa nd inspect feet daily

use creams/lotions to prevent dry skin/callus formation

feet measured when buying shoes

avoid walking barefoot

medical treatment when foot injury

avoid thermal injury e.g. hot water bottle

avoid self treatment of corns etc

Question 17

Biochemical diagnosis of DKA

Question 18

Causes of DKA

Answer 18

Presentation

interruption of insulin therapy

infection

surgery/trauma

MI

Question 19

Anion gap calculation

Question 20

Causes of acidosis with increased anion gap

Answer 20

Causes (LTKR)

Lactate

Toxins

Ketones

Renal

Causes (CATMUDPILES)

CO, CN

Alcoholic ketoacidosis and starvation ketoacidosis

Toluene

Metformin, Methanol

Uremia

DKA

Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde

Iron, Isoniazid

Lactic acidosis

Ethylene glycol

Salicylates

Question 21

Management of DKA

Answer 21

Insulin

Insulin dose should be based on weight. Sliding scales should not be used, as they can be inaccurate in overweight and pregnant patients

The type of insulin regimen is often referred to as a Fixed rate Intravenous Insulin Infusion, or FRIII

Check the effectivesness of the FRIII using blood ketones and revise the dose if it is not effective

If bedside blood ketone testing is not available, venous blood gasses can be used to asses bicarbonate level, but only for the first 6 hours, as this becomes inaccurate after infusion of large amount of normal saline.

Fluids

Use IV 0.9% sodium chloride (normal saline)

If hypotensive (systolic BP <90mmHg) give a bolus of 500mls normal saline. If still hypotensive, seek senior help. Consider discussion with ICU, and think about other possible causes of hypotension.

Once hypotension is resolved, or if it is not present at presentation, patient will still require large amounts of IV fluid. A typical regimen might be 1L normal saline in the first hour, then 1L over 2 hours, then 1L over 4 hours etc, but be wary of a ‘one size fits all’ regimen

Monitor electrolytes, particularly potassium closely. You will likely need to replace potassium, which can be done by adding KCl to the bags of normal saline. Be careful not to infuse potassium too quickly.

Potassium
DKA patients are at risk of both hypokalaemia, and hyperkalaemia. Initially they are often hyperkalaemic, but their total body potassium is low. This is because potassium is taken up into cells with insulin, so with a lack of insulin, extra cellular potassium rises, and the intracellular level falls.
Titrate potassium replacement to the potassium level, as measured on hourly venous blood gasses.

K+ >5.5mmol/L – dont replace

K+ 3.5 – 5.5 mmol/L – replace by using 40mmol/L in infused solution

K+ <3.5 – seek senior help – additional potassium replacement may be require

blood gasses can be used to asses bicarbonate level, but only for the first 6 hours, as this becomes inaccurate after infusion of large amount of normal saline.

Fluids

Use IV 0.9% sodium chloride (normal saline)

If hypotensive (systolic BP <90mmHg) give a bolus of 500mls normal saline. If still hypotensive, seek senior help. Consider discussion with ICU, and think about other possible causes of hypotension.

Once hypotension is resolved, or if it is not present at presentation, patient will still require large amounts of IV fluid. A typical regimen might be 1L normal saline in the first hour, then 1L over 2 hours, then 1L over 4 hours etc, but be wary of a ‘one size fits all’ regimen

Monitor electrolytes, particularly potassium closely. You will likely need to replace potassium, which can be done by adding KCl to the bags of normal saline. Be careful not to infuse potassium too quickly.

Potassium
DKA patients are at risk of both hypokalaemia, and hyperkalaemia. Initially they are often hyperkalaemic, but their total body potassium is low. This is because potassium is taken up into cells with insulin, so with a lack of insulin, extra cellular potassium rises, and the intracellular level falls.
Titrate potassium replacement to the potassium level, as measured on hourly venous blood gasses.

K+ >5.5mmol/L – dont replace

K+ 3.5 – 5.5 mmol/L – replace by using 40mmol/L in infused solution

K+ <3.5 – seek senior help – additional potassium replacement may be require

Question 22

Complications of DKA treatment

Answer 22

Fluid overload

hypoglycaemia

hypokalaemia

Question 23

Warning signs of hypoglycaemia

Answer 23

Autonomic: sweating, palpitations, shaking, hunger

neurological: confusion, drowsiness, slurred speech

Question 24

What conditions do T1DM sufferers need regular screening for?

Answer 24

hypo/hyperthyroidism

coeliac

commonly associated, make glycaemic control difficult

Question 25

Causes of peripheral neuropathy

Answer 25

A- alcohol

B- B12 deficiency (+SADC)

C- CKD (+carcinoma)

D- diabetes and drugs

E- every vasculitis (RA, Polyarteritis)

Question 26

Fibres and what they transmit, and what knocks them out

Answer 26