Diabetes

Question 1

What are the 3 key features of DKA?

Answer 1

HyperG >11
Ketones +++ on dipstick or >3 on bloods
Metabolic acidosis: pH <7.3 or HCO3- <15

Question 2

What are the signs of DKA?

Answer 2

Polyuria & polydipsia
N&V
Weight loss
Confsion & drowsy
Kussmaul breathing
Abdo pain

Question 3

What is kussmaul breathing?

Answer 3

Deep hyperventilation to expel CO2 for respiratory compensation

Question 4

What investigations should be done for DKA?

Answer 4

Urine dip: +++ ketones, +++ glucose
Blood Glucose: >11
Capillary ketones: >3
ABG: Metabolic acidosis
Other bloods: FBC, U&E, LFT

Question 5

How is DKA managed?

Answer 5

1) FLUIDS: 0.9% NaCl
2) Insulin: 50u Actrapid w/50ml saline fixed rate 0.1u/kg/hr

Once glucose <14 → 10% glucose continued till ketones <0.3, pH .7.3, HCO3- >18

3) K+ Sulphate 40mls at 125ml/hr in 2nd bag of NaCl

Question 6

Should any regular meds be continued in DKA?

Answer 6

ALWAYS continue patients long acting insulin

Question 7

What is the fluid regimen in DKA?

Answer 7

1L → 1hr
1L → 2hr
1L → 2hr
1L → 4hr
1L → 4hr
1lL→ 6hr
1L → 6hr

Question 8

What are the complications of DKA?

Answer 8

↓Mg: <0.5 then give MgSO4 in 50ml saline over 15-30mins

Question 9

What is the mechanism of DKA?

Answer 9

Too much glucose
Body used all insulin
Lack of insulin causes body to metabolise fat (lipolysis)
Produces ketones

Question 10

Define hypoG?

Answer 10

Glucose <4mmol

Question 11

What can cause hypoG?

Answer 11

DRUGS: Insulin, OH-, beta-blockers, salicylates, sulfonylureas
ORGAN FAILURE: Acute LF, adrenal failure, hypopituitarism
INFECTION
TUMOURS: Insulinoma

Question 12

What are the clinical features of hypoG?

Answer 12

<3.6= sympathetic overactivity:
- Tachy + anxious
-Sweating + pallor + Tremor
-Cold extremities
<2.6 = neuroglycopenia
-Confusion
-Slurred speech + blurred vision
-Seizures/coma

Question 13

How is hypoG investigated?

Answer 13

Blood glucose:
<4 = hypoG
<2.2 = Severe attack
< 1.5 = Coma
Other bloods: U&amp;E

Question 14

How is hypoG managed?

Answer 14

1) Safe swallow → Fast acting glucose 10-20g
RECHECK GLUCOSE 10-15mins → Rx if <4
2) Unsafe swallow → IV 100ml 20% glucose OR IM glucagon 1mg
3) Carb rich snack when able to eat
4) Consider cause, Alcoholic → IV Pabrinex

Question 15

What is HHS?

Answer 15

Severe uncorrected hyperG
In presence of residual insulin production
Usually T2DM
With massive dehydration but NOT ketoacidotic

Question 16

How does HHS present?

Answer 16

Unknown Hx of DM
Insidious polyuria + polydipsia
SEVERE DEHYRDATION
Weakness- leg cramps
↓Consciousness 
↓BP, ↑HR, ↑RR

Question 17

How is HHS investigated?

Answer 17

Glucose: >33
U&E: ↑Urea > Cr, ↑Na 
FBC: Polycythaemia + leucocytosis
Plasma Osmolality: >350mosm/kg- DIAGNOSTIC
ABG: Normal

Question 18

Why is there an ↑Na in HHS?

Answer 18

Glucose draws H2O out of cells
Causes dilution ↓Na
Once Tx started ↑↑Na

Question 19

How is HHS managed?

Answer 19

1) FLUID replacement: 1/2 rate of DKA, 0.9% NaCl
If Na >160 use 0.45% NaCl for 3L
2) VTE prophylaxis → Tinz
3) If ketonuria → Insulin infusion

Question 20

What is the fluid regimen in HHS?

Answer 20

1L → 30mins
1L & K+ → 2hr for 4hr (x2)
1L & K+ → 6hr until rehydrated (usually 48hours)

Question 21

Define T1DM

Answer 21

Autoimmune destruction of pancreatic B cells leading to ↓insulin production

Question 22

What are the classic symptoms of T1DM?

Answer 22

Polyuria
Polydipsia
Weight loss
Fatigue

Question 23

How is T1DM diagnosed?

Answer 23

1. Clinical Sx of hyperG
AND
- Fasting glucose >7
OR
-Random plasma glucose >11.1
OR
OGTT 2hr post >11.1
OR
HbA1c >48

Question 24

What HbA1c level is classed as pre-diabetic?

Answer 24

42-47

Question 25

How is diabetes linked to nephropathy?

Answer 25

Glucose damages glomeruli & renal arteries

Need to inhibit RAAS to protect kidneys & control HTN (ACEi/Losartan)

Question 26

What are the signs of diabetic nephropathy?

Answer 26

Microalbuminuria: ACR >1
Urine dip: + protein
Urine ACR >3

Question 27

What 9 things need to be considered at an annual diabetic review?

Answer 27

1) Weight + BMI
2) Creatinine
3) Urine ACR
4) Cholesterol
5) HbA1c
6) BP (<140/90)
7) Smoking status
8) Eye exam
9) Foot exam

Question 28

What are the blood glucose targets throughout the day?

Answer 28

Aim for: 5-7
Waking: 4-7
Pre-meal: 5-9
Post-meal/post-op: 6-10

Question 29

How is T1DM managed?

Answer 29

1st line) Basal-bolus insulin

Question 30

How is T2DM managed?

Answer 30

1) Exercise + diet
HbA1c not at target in 3months
2) Metformin OR Gliclazide
HbA1c not at target in 3months
3) Metformin + Gliclazide/DDP-4/Piaglitazone/
HbA1c not at target in 3months
4) Triple therapy OR Insulin

Question 31

What are the 2 main categories of Sx in diabetic neuropathy?

Answer 31

• Neuropathy: Charcot foot/joint = swelling, distortion, flat foot, loss of sensation, neuropathic ulcers (NOT painful on plantar)
• Ischaemia: Absent foot pulses, ↓ABPI, Intermittent claudication