Diabetes Emergencies

Question 1

what is DKA?

Answer 1

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)

Question 2

which diabetes does DKA occur in?

Answer 2

can occur in both

a bit more common in type 1

Question 3

3 consequences of absolute/relative insulin deficiency?

Answer 3

hyperglycaemia
acidosis
hyperosmolarity

Question 4

pathophysiology of DKA?

Answer 4

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

Question 5

biochemical features of DKA?

Answer 5

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

Question 6

what can affect DKA risk?

Answer 6

higher HbA1c = higher risk

lower socioeconomic group = higher risk

Question 7

describe mortality rates in DKA?

Answer 7

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

Question 8

what generally causes death in DKA?

Answer 8

adults 
- hypokalaemia
- aspiration
- pneumonia
- ARDS
- co-morbidities
children
- cerebral oedema

Question 9

what can precipitate DKA?

Answer 9

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

Question 10

what are the typical symptoms and signs of DKA?

Answer 10

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

Question 11

what is considered high glucose on glucose meter?

Answer 11

> 28

Question 12

management principles of DKA?

Answer 12

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

Question 13

what risks must be addressed in DKA?

Answer 13

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

Question 14

how can you monitor ketones?

Answer 14

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

Question 15

what are the 2 predominant features in HHS?

Answer 15

hyperglycaemia
hyperosmolority
slight acidosis

Question 16

biochemical features of HHS?

Answer 16

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

Question 17

risk factors for HHS?

Answer 17

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

Question 18

how do you calculate osmolality?

Answer 18

2x[Na] + urea + glucose

Question 19

normal osmolality range?

Answer 19

275-295

Question 20

DKA vs HHS

Answer 20

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

Question 21

DKA treatment vs HHS treatment?

Answer 21

DKA = insulin
HHS = diet/OHA/insulin (sometimes)

Question 22

how is alcohol induced ketoacidosis managed?

Answer 22

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

Question 23

biochemical features of alcoholic/starvation ketoacidosis?

Answer 23

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

Question 24

3 main characteristics of alcohol-induced ketoacidosis?

Answer 24

acetate
acetoacetate
beta-OHB

Question 25

targets for in patient blood sugar?

Answer 25

6-10

4-12 is accepted

Question 26

considerations in surgery if patient is diabetic?

Answer 26

anaesthetic risk due to autonomic neuropathy
foot risk
glycaemic control

Question 27

what is lactate and how is it cleared from the body?

Answer 27

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

Question 28

what is the normal level of lactate?

Answer 28

0.6-1.2 mmol/L

can rise to 10mmol/L in high exercise

Question 29

what is the ion gap?

Answer 29

concentration of positively charged proteins - concentration of negatively charged proteins
useful in determining the cause of an acidosis

Question 30

what is the normal range of ion gap?

Answer 30

10-18 mmol/L
high = acidosis
low = alkalosis

Question 31

what is Type A lactic acidosis?

Answer 31

associated with tissue hypoxaemia

• infarction
• cardiogenic shock
• hypovolaemic shock
• sepsis
• haemorrhage

Question 32

what is type B lactic acidosis?

Answer 32

may occur in liver disease, leukaemic states, diabetes

Question 33

what are the clinical features of lactic acidosis?

Answer 33

hyperventilation
mental confusion
stupor or coma if severe

Question 34

what are the lab findings in lactic acidosis?

Answer 34

reduced bicarbonate
raised anion gap
variable glucose - often raised
no ketonaemia
raised phosphate

Question 35

how is lactic acidosis managed?

Answer 35

treat underlying condition
- fluids and antibiotics
withdraw causative medication (metformin)

Question 36

what causes HHS and what can precipitate it?

Answer 36

diuretics and/or steroids
fizzy drinks
can be precipitated by new diagnosis or infection

Question 37

how is HHS treated specifically?

Answer 37

fluids
insulin - slowly delivered (sometimes)
sodium
Consider likely co-morbidities (vascular event)
- LMWH given for all unless contraindicated

Question 38

how is DKA diagnosed?

Answer 38

biochemistry

• ketonaemia >3 or ketonuria >2
• Blood glucose >11 (median = 40)
• bicarbonate <15 or venous pH <7.3

Question 39

what are the typical biochemistry findings in DKA?

Answer 39

ketonaemia
hyperglycaemia
low bicarbonate/low pH
low/low normal sodium
low potassium
high lactate
high WCC
high creatinine
amylase often raised