Diabetes Emergencies Flashcards

1
Q

what is DKA?

A

diabetic ketoacidosis
disordered metabolic state usually occurring in context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones (i.e glucagon, adrenaline, cortisol and growth hormone)

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2
Q

which diabetes does DKA occur in?

A

can occur in both

a bit more common in type 1

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3
Q

3 consequences of absolute/relative insulin deficiency?

A

hyperglycaemia
acidosis
hyperosmolarity

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4
Q

pathophysiology of DKA?

A

absolute or relative insulin deficiency leads to activation of stress hormones
causes increase in lipolysis, proteolysis and glycogenolysis and a decrease in glucose utilization
results in hyperglycaemia, acidosis and hypersmolality

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5
Q

biochemical features of DKA?

A

ketonaemia >3 or significant ketonuria >2
blood glucose >11 or known DM
bicarbonate <15 or venous pH <7.3

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6
Q

what can affect DKA risk?

A

higher HbA1c = higher risk

lower socioeconomic group = higher risk

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7
Q

describe mortality rates in DKA?

A

fairly low (2-5%) but higher in developing countires

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8
Q

what generally causes death in DKA?

A
adults 
- hypokalaemia
- aspiration
- pneumonia
- ARDS
- co-morbidities
children
- cerebral oedema
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9
Q

what can precipitate DKA?

A

new diagnosis
infection
drug and alcohol use
poor glycaemic control = biggest cause

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10
Q

what are the typical symptoms and signs of DKA?

A
thirst and polyuria
dehydration
flushed
vomiting
abdo pain/tenderness
breathless (kussmauls)
can sometimes smell ketones on breath
underlying sepsis
gastroenteritis
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11
Q

what is considered high glucose on glucose meter?

A

> 28

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12
Q

management principles of DKA?

A

replace losses
- NaCl then dextrose when glucose hits 15, insulin and potassium
address risks

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13
Q

what risks must be addressed in DKA?

A

is NG tube needed?
monitor potassium
prescribe prophylactic LMWH
source sepsis - CXR, blood culture, MSSU +/- viral titres

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14
Q

how can you monitor ketones?

A

blood ketone testing
<6 = normal
urine ketone testing
- indicates levels 2-4 hrs previously

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15
Q

what are the 2 predominant features in HHS?

A

hyperglycaemia
hyperosmolority
slight acidosis

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16
Q

biochemical features of HHS?

A
hypovolaemia
hyperglycaemia (more than DKA, >50)
No/mild ketonaemia (<3 mmol/L)
Bicarbonate >15 mmol/L or venous pH >7.3
Osmolality >320 mosmol/kg
sodium high normal/raised
significant renal impairment
17
Q

risk factors for HHS?

A
older patients
type 2 diabetes
afro-caribbean
CV disease
sepsis
medication - steroids, thiazides
high refined carbohydrate intake pre-presentation
18
Q

how do you calculate osmolality?

A

2x[Na] + urea + glucose

19
Q

normal osmolality range?

20
Q

DKA vs HHS

A

HHS usually seen in older patients and type 2 rather than type 1
HHS has a higher mortality

21
Q

DKA treatment vs HHS treatment?

A
DKA = insulin
HHS = diet/OHA/insulin (sometimes)
22
Q

how is alcohol induced ketoacidosis managed?

A
IV pabrinex
IV fluids
IV anti-emetics
insulin may be needed on occasion
address alcohol dependency
23
Q

biochemical features of alcoholic/starvation ketoacidosis?

A

dehydration
ketonaemia >3 or significant ketonuria >2
bicarbonate <15 or venous pH <7.3
normal glucose

24
Q

3 main characteristics of alcohol-induced ketoacidosis?

A

acetate
acetoacetate
beta-OHB

25
targets for in patient blood sugar?
6-10 | 4-12 is accepted
26
considerations in surgery if patient is diabetic?
anaesthetic risk due to autonomic neuropathy foot risk glycaemic control
27
what is lactate and how is it cleared from the body?
end product of anaerobic metabolism of glucose originates from red cells, skeletal muscle, brain and renal medulla clearance requires hepatic uptake and aerobic conversion to pyruvate then glucose
28
what is the normal level of lactate?
0.6-1.2 mmol/L | can rise to 10mmol/L in high exercise
29
what is the ion gap?
concentration of positively charged proteins - concentration of negatively charged proteins useful in determining the cause of an acidosis
30
what is the normal range of ion gap?
10-18 mmol/L high = acidosis low = alkalosis
31
what is Type A lactic acidosis?
associated with tissue hypoxaemia - infarction - cardiogenic shock - hypovolaemic shock - sepsis - haemorrhage
32
what is type B lactic acidosis?
may occur in liver disease, leukaemic states, diabetes
33
what are the clinical features of lactic acidosis?
hyperventilation mental confusion stupor or coma if severe
34
what are the lab findings in lactic acidosis?
``` reduced bicarbonate raised anion gap variable glucose - often raised no ketonaemia raised phosphate ```
35
how is lactic acidosis managed?
treat underlying condition - fluids and antibiotics withdraw causative medication (metformin)
36
what causes HHS and what can precipitate it?
diuretics and/or steroids fizzy drinks can be precipitated by new diagnosis or infection
37
how is HHS treated specifically?
fluids insulin - slowly delivered (sometimes) sodium Consider likely co-morbidities (vascular event) - LMWH given for all unless contraindicated
38
how is DKA diagnosed?
biochemistry - ketonaemia >3 or ketonuria >2 - Blood glucose >11 (median = 40) - bicarbonate <15 or venous pH <7.3
39
what are the typical biochemistry findings in DKA?
``` ketonaemia hyperglycaemia low bicarbonate/low pH low/low normal sodium low potassium high lactate high WCC high creatinine amylase often raised ```