Diabetes - Complications, Emergencies & Acute Illness Flashcards
What complication occurs in at least 50% of diabetic men because of a vascular disease and/or nephropathy?
Erectile dysfunction
In which type of diabetes is neuropathy most common?
Type 1
Describe the typical distribution of symptoms of peripheral neuropathy?
‘Glove and stocking’
What are some potential complications of peripheral neuropathy?
Painless trauma, foot ulcers, Charcot foot
What oral painkillers can be used to treat peripheral neuropathy?
Amitriptyline, gabapentin
What topical treatment can be used in the management of localised pain from peripheral neuropathy?
Capsaicin cream
What is the main gastrointestinal problem which occurs as a result of autonomic neuropathy?
Gastroparesis
Autonomic neuropathy can lead to abnormal temperature regulation. This can cause sweating when?
At night or when eating
What effect does autonomic neuropathy have on the eyes?
Makes them less responsive to changes in light
What is the name for the type of neuropathy which appears suddenly and affects only specific nerves?
Focal neuropathy
Which type of neuropathy usually starts with unilateral pain in the thighs/hips/buttocks and is more common in elderly type 2 diabetics?
Proximal neuropathy
What is used to screen for diabetic nephropathy?
Urinary albumin: creatinine ratio
What type of urine sample should ideally be used to take a urinary albumin: creatinine ratio?
Early morning sample
All patients with microalbuminuria should be started on what medication?
ACE inhibitor or ARB
Diabetes is a risk factor for which pathologies affecting the eyes?
Retinopathy, maculopathy, cataracts and glaucoma
What effect does acute hyperglycaemia have on the eyes, but is reversible?
Blurred vision
A blood glucose of less than what value is generally considered as hypoglycaemia?
4mmol/L
What are some factors which may contribute to reduced awareness of hypoglycaemia?
Frequent hypos, long duration of disease
What are some examples of common drugs (other than diabetic drugs) which may cause hypoglycaemia as a side effect?
Beta blockers, ACE inhibitors, aspirin (in overdose) and alcohol
What other endocrine condition, not specifically affecting the pancreas, can cause hypoglycaemia?
Addison’s disease
How should hypoglycaemia be managed if the patient is able to swallow?
Oral glucose and a long-acting carbohydrate
How should hypoglycaemia be managed if the patient cannot swallow but there is IV access?
200-300mls 10% IV dextrose
How should hypoglycaemia be managed if the patient cannot swallow and there is no IV access?
1mg IM glucagon (repeat after 20 mins)
Once an individual who has been hypoglycaemic regains consciousness, what adverse effect may they experience?
Nausea/vomiting
The production of acetone as a by-product of ketoacidosis produces what clinical sign?
Fruity smelling breath
What happens to the blood glucose level in DKA?
It is significantly raised, usually > 11mmol/L
The lack of insulin in DKA can lead to what electrolyte abnormality?
Hyperkalaemia
Kussmaul’s respiration is a sign of what diabetic emergency?
DKA
In DKA, what abnormal sign may occur, even in the absence of infection?
Raised WCC
Which acid base disorder is seen in DKA?
Metabolic acidosis
What happens to the anion gap in DKA?
Raised
In DKA, the venous pH is usually less than what value?
7.3
In DKA, the venous bicarbonate is usually less than what value?
15mmol/L
What are the 3 key biochemical features of DKA?
Hyperglycaemia, ketonaemia and acidaemia
In DKA, the blood ketones are usually more than what value?
3mmol/L
What does urine ketone testing indicate?
The ketone level 2-4 hours previously
Which blood should be checked for ketones- venous or arterial?
Venous
What investigations are performed to assess for an underlying infection in those with DKA?
MSU, CXR, blood cultures
What fluids should be given if a patient with DKA has a systolic BP < 90mmHg?
500ml bolus of 0.9% saline (repeat if necessary, seek senior help)
What fluids should be given initially to patients with DKA who have a systolic BP > 90mmHg or have responded to the first bolus of saline?
1L 0.9% saline over 1 hour
What are the 4 main principles of treatment for DKA?
Fluid replacement, insulin, glucose, potassium replacement
How should insulin be given in DKA?
50 units Actrapid in 50ml 0.9% saline
Should the patients normal insulin regimen be continued for those in DKA?
Continue long acting insulin, withhold short acting insulin
You should start to give 10% glucose (or 5% dextrose) in the treatment of DKA when the blood glucose falls below what value?
14mmol/L
All patients in DKA and HHS should be started on what medication in order to prevent significant complications?
LMWH
Fixed rate insulin should be continued in DKA until what parameters are met?
Blood ketones < 0.3mmol/L, venous pH > 7.3, venous bicarbonate > 18mmol/L
Potassium should not be added to which fluid bag in the treatment of DKA?
The first bag
Potassium can be added to fluids in the treatment of DKA when the urine output is greater than what?
30mls/hour
If the serum potassium is 3.5-5.5, how much KCl should be added per litre of IV fluid in DKA?
40mmol
What is the most significant complication of DKA, that mostly affects children and young people?
Cerebral oedema
What is the typical demographic of individual to be affected by HHS?
Older, type 2 diabetic
What are the 3 main biochemical features of HHS?
Significant dehydration, hyperglycaemia and raised serum osmolality
How are patients with HHS rehydrated?
0.9% saline IV infusion over 48 hours
What electrolyte may need replaced in individuals with HHS?
Potassium
All patients with HHS should be screened for what?
A silent vascular event
What are some common drugs which may precipitate HHS?
Steroids and thiazide diuretics
What is a rare but serious complication of diabetes with metformin use?
Lactic acidosis
Lactic acidosis is defined as a blood lactate of greater than what?
5mmol/L
What drug must be stopped in individuals with lactic acidosis?
Metformin
In those with diabetes, the aim is to achieve an HbA1c of less than what before undergoing elective surgery?
69mmol/mol
The night before undergoing surgery, should normal insulin therapy be continued for insulin dependent diabetics?
Yes
On the day of surgery, what normal insulin treatment should be continued in insulin dependent diabetics?
Long acting (basal) insulin
Which types of routine insulin should be omitted when patients are being treated with IV insulin?
Rapid acting and mixed insulin
IV insulin is given as an IV infusion of what type of insulin?
50 units Actrapid in 50mls 0.9% saline
If an insulin dependent diabetic is on the PM list for surgery, should they be given their normal morning insulin dose?
Yes
If an insulin dependent diabetic patient is eating and drinking post-operatively, when should their normal insulin regimen be restarted?
With the evening meal
What is the only oral hypoglycaemic agent that should not be given the night before surgery?
Long acting sulfonylureas e.g. glibenclamide
If it is unlikely that diabetic patients will be eating and drinking after surgery, when should a variable rate IV insulin infusion be started?
2 hours prior to surgery
When can metformin be continued after the use of IV contrast?
If the patient has a normal creatinine and/or eGFR > 60 mls/min
If a patient has an eGFR < 60mls/min and/or a raised creatinine, how long should metformin be stopped for after the use of IV contrast?
48 hours
Should oral hypoglycaemic agents be continued in acute illness?
Yes
When should metformin be stopped in patients who are acutely unwell?
If they are becoming dehydrated
Should insulin be continued in acute illness?
Yes
As a general rule of thumb, the corrective dose of insulin to be given in acute illness is worked out how?
Total daily insulin dose divided by 6 (maximum 15 units)
In children with DKA, when should insulin be given?
After 1 hour of IV fluids
If an individual with known diabetes experiences bloating and vomiting after meals, in addition to erratic blood glucose control, what complication should you consider? What drug can be given to control the symptoms?
Gastroparesis (autonomic neuropathy) - give metoclopramide
If an individual has received insulin treatment for DKA and then they experience a cardiac arrhythmia, what electrolyte abnormality is likely responsible?
Hypokalaemia
In DKA, is IV insulin given at a fixed or variable rate?
Fixed
At what rate is IV insulin given in DKA?
0.1 units/kg/hour
When giving IV glucose in DKA, what rate should it be infused at?
125ml/hour
In the treatment of DKA, what should be given to patients when their blood glucose falls below 14mmol/L?
IV infusion of 10% glucose
