Diabetes acute complications

Question 1

Acute complications of diabetes

Answer 1

Hypoglycemia; Hyperglycemia: Diabetic KetoAcidosis, Hyperglycemic Hyperosmolar State; Infection

Question 2

Infections in diabetes

Answer 2

Bacteria love Hyperglycemia; Blood supply reduced by vascular disease; Neutrophil function impaired if glucose >10mmol/l: adhesion, rolling, chemotaxis, phagocytosis, superoxide generation, cell killing, etc.; UTI, candida infections, acne, abscesses, foot ulcers, gangrene, etc

Question 3

DKA - what is it, and give description

Answer 3

Diabetic ketoacidosis. It’s a metabolic emergency. Hyperglycemia, ketonemia, metabolic acidosis, dehydration (water follows glucose out in urine); results from insufficient insulin for body’s needs - can be tipped by heart attack, GI bleed, pancreatitis or trauma

Question 4

How does DKA develop?

Answer 4

Insert chart. Kidneys stop working well, stomach also, muscles take up less glucose

Question 5

Why do you need to give insulin for DKA?

Answer 5

Switch off ketogenesis, NOT to make glucose normal immediately. Just switch off the bad.

Question 6

How do you treat DKA?

Answer 6

Give fluid - increases perfusion to kidneys (can start urinating glucose again - ok here) and muscles (easier uptake); Give insulin: turn off glycolysis and gluconeogenesis from liver and protein break down.

Question 7

What happens to potassium in DKA? With insulin tx?

Answer 7

Acidosis causes H+ to go into cells and K+ out, then it gets excreted in urine. Insulin stimulates Na/K pump to keep K+ in cells, but can lead to hypokalemia and cause arrhythmias and stuff unless you give K as well! So give them insulin and K+ together!

Question 8

Signs and Symptoms of DKA?

Answer 8

Osmotic; Weight Loss; Nausea & Vomiting (ddx with gastroenteritis!); Abdo pain. Dehydration, Hypotension, Tachycardia, Kussmaul’s breathing (deep, sighing resp stimulated by acid - blow of CO2); decreased Level of consciousness; ketones on breath sometimes.

Question 9

How to diagnose DKA?

Answer 9

Ketonuria/Ketonemia (dipstick etc); pH < 7.3 (arterial blood gases); serum bicarb < 15 mmol/l; hyperglycemia (14 - 35 mmol/l); anion gap >14 mmol/l - K - ketones, I - ingestion, L - lactic acid, U - uremia. Tests: Urinalysis, Plasma glucose, lytes, creatinine, bicarb, β-hydroxybutyrate, ABG, CBC, CXR, ECG, Troponin, Urine culture, Blood cultures, Amylase/Lipase

Question 10

Tx for DKA (again)

Answer 10

Fluid: Dilutes glucose, Improves perfusion: Muscle, Kidney. Insulin: Turn off ketones and glucose production, [Increase glucose uptake into muscle]. Potassium! Give some dextrose eventually to avoid hypo. CHART

Question 11

Should you give bicarbonate to someone with DKA?

Answer 11

generally NO. Consider after you’ve started treating and they are still getting worse/not improving in pH. Other risks: skin necrosis (can cause a burn), hypokalemia, paradoxical worsening of cerebral acidosis

Question 12

Other considerations with DKA

Answer 12

Conscious level: need intubation to protect airway? need n/g tube. Urine output: need catheter? Immobile and increased viscosity: need anticoagulation? Oral K+ supplements?

Question 13

Complications of DKA

Answer 13

Cerebral Edema -> coma -> death. ARDS (adult res distress syndrome) -> hypoxia -> death. Underlying illness (sepsis, MI) -> death. Hypokalemia -> arrhythmia -> death. Hypoglycemia

Question 14

What is the classic emergency for type 1? for type 2?

Answer 14

Type 1: DKA. Type 2: Hyperosmolar Hyperglycemic Syndrome (HHS) / HONK

Question 15

What is HHS?

Answer 15

Very high glucose and osmolality, relatively low insulin, not acidic, low/0 ketones

Question 16

What is osmolality?

Answer 16

osmolality = 2 x [Na+] + [glucose] + [urea]. Normal is 285-295. High causes the loss of consciousness

Question 17

Causes of HHS

Answer 17

intercurrent illness; infection; MI; dehydration; steroids; new diagnosis

Question 18

Tx for HHS

Answer 18

ABC’s; Look for cause; Rehydration - caution (watch for the lungs and heart); Insulin - start at 4 units/hr; Anticoagulate

Question 19

Hypoglycemia symptoms (2 categories)

Answer 19

Adrenergic: shaky, sweaty, hungry, palpitations, anxiety, hunger. Neuroglycopenic: confusion, blurred vision, tired, dizzy, slurred speech, inco-ordination, seizures &/or coma - almost drunk-like

Question 20

Long term risks with hypoglycaemia

Answer 20

Hypoglycemia unawareness - glucose sensitivity is “reset” to a lower level (often due to recurrent mild episodes, exacerbated by sleep, alcohol & exercise). Cognitive impairment: due to cumulative effects of recurrent hypoglycemia. Permanent brain injury: due to acute, severe hypoglycemic episodes

Question 21

Normal response to hypoglycemia

Answer 21

Stop insulin, increase glucagon, increase epi, increase cortisol, then coma/seizure. Diabetics tho: probably just took some insulin, so it blocks glucagon and epi, so more at risk.

Question 22

Rx for hypo unawareness

Answer 22

relax targets; increased frequency of sbgm; scrupulous avoidance of hypoglycemia; challenge complacency (esp nocturnal lows); reinforce education on precipitants

Question 23

Risk factors for hypoglycemia

Answer 23

Elderly, Renal impairment, Thin, Missed meals, Exercise, Insulin, Secretagogues

Question 24

History etc to take with patients re hypoglycaemia

Answer 24

any episodes?: frequency / severity, any severe episodes? symptoms, how detected, glycemic threshold, paramedic / ER/ glucagon use -“Do you ever get surprises?” precipitants: diurnal pattern, meal pattern, skipped meals, relationship with exercise; fear of hypoglycemia? Blood Glucose Diary / Insulin Doses, Meter Download; Injection Sites; HR / Postural BP / Autonomic dysfunction; (consider Addison’s (am cortisol) / Celiac Disease (anti-transglutaminase)). Educate!

Question 25

How to treat hypoglycaemia

Answer 25

Don’t overtreat! 15 g Carbohydrate, Check BG after 15 min, If BG < 4 repeat dose of Carb. Severe: Glucagon 1mg im injection, iv Dextrose

Question 26

Will taking glucagon work to reverse hypoglycaemia all the time?

Answer 26

No, because it depends on glycogen stored in the liver. People with liver disease or who all malnourished will not work. Also insulin counteracts it, so that could also be a problem

Question 27

Compare causes of DKA and HHS

Answer 27

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