Diabetes acute complications Flashcards
Acute complications of diabetes
Hypoglycemia; Hyperglycemia: Diabetic KetoAcidosis, Hyperglycemic Hyperosmolar State; Infection
Infections in diabetes
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
DKA - what is it, and give description
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
How does DKA develop?
Insert chart. Kidneys stop working well, stomach also, muscles take up less glucose
Why do you need to give insulin for DKA?
Switch off ketogenesis, NOT to make glucose normal immediately. Just switch off the bad.
How do you treat DKA?
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.
What happens to potassium in DKA? With insulin tx?
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!
Signs and Symptoms of DKA?
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.
How to diagnose DKA?
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
Tx for DKA (again)
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
Should you give bicarbonate to someone with DKA?
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
Other considerations with DKA
Conscious level: need intubation to protect airway? need n/g tube. Urine output: need catheter? Immobile and increased viscosity: need anticoagulation? Oral K+ supplements?
Complications of DKA
Cerebral Edema -> coma -> death. ARDS (adult res distress syndrome) -> hypoxia -> death. Underlying illness (sepsis, MI) -> death. Hypokalemia -> arrhythmia -> death. Hypoglycemia
What is the classic emergency for type 1? for type 2?
Type 1: DKA. Type 2: Hyperosmolar Hyperglycemic Syndrome (HHS) / HONK
What is HHS?
Very high glucose and osmolality, relatively low insulin, not acidic, low/0 ketones
What is osmolality?
osmolality = 2 x [Na+] + [glucose] + [urea]. Normal is 285-295. High causes the loss of consciousness
Causes of HHS
intercurrent illness; infection; MI; dehydration; steroids; new diagnosis
Tx for HHS
ABC’s; Look for cause; Rehydration - caution (watch for the lungs and heart); Insulin - start at 4 units/hr; Anticoagulate
Hypoglycemia symptoms (2 categories)
Adrenergic: shaky, sweaty, hungry, palpitations, anxiety, hunger. Neuroglycopenic: confusion, blurred vision, tired, dizzy, slurred speech, inco-ordination, seizures &/or coma - almost drunk-like
Long term risks with hypoglycaemia
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
Normal response to hypoglycemia
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.
Rx for hypo unawareness
relax targets; increased frequency of sbgm; scrupulous avoidance of hypoglycemia; challenge complacency (esp nocturnal lows); reinforce education on precipitants
Risk factors for hypoglycemia
Elderly, Renal impairment, Thin, Missed meals, Exercise, Insulin, Secretagogues
History etc to take with patients re hypoglycaemia
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!
How to treat hypoglycaemia
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
Will taking glucagon work to reverse hypoglycaemia all the time?
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
Compare causes of DKA and HHS
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