Diabetes Emergencies Flashcards
what is DKA?
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)
which diabetes does DKA occur in?
can occur in both
a bit more common in type 1
3 consequences of absolute/relative insulin deficiency?
hyperglycaemia
acidosis
hyperosmolarity
pathophysiology of DKA?
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
biochemical features of DKA?
ketonaemia >3 or significant ketonuria >2
blood glucose >11 or known DM
bicarbonate <15 or venous pH <7.3
what can affect DKA risk?
higher HbA1c = higher risk
lower socioeconomic group = higher risk
describe mortality rates in DKA?
fairly low (2-5%) but higher in developing countires
what generally causes death in DKA?
adults - hypokalaemia - aspiration - pneumonia - ARDS - co-morbidities children - cerebral oedema
what can precipitate DKA?
new diagnosis
infection
drug and alcohol use
poor glycaemic control = biggest cause
what are the typical symptoms and signs of DKA?
thirst and polyuria dehydration flushed vomiting abdo pain/tenderness breathless (kussmauls) can sometimes smell ketones on breath underlying sepsis gastroenteritis
what is considered high glucose on glucose meter?
> 28
management principles of DKA?
replace losses
- NaCl then dextrose when glucose hits 15, insulin and potassium
address risks
what risks must be addressed in DKA?
is NG tube needed?
monitor potassium
prescribe prophylactic LMWH
source sepsis - CXR, blood culture, MSSU +/- viral titres
how can you monitor ketones?
blood ketone testing
<6 = normal
urine ketone testing
- indicates levels 2-4 hrs previously
what are the 2 predominant features in HHS?
hyperglycaemia
hyperosmolority
slight acidosis
biochemical features of HHS?
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
risk factors for HHS?
older patients type 2 diabetes afro-caribbean CV disease sepsis medication - steroids, thiazides high refined carbohydrate intake pre-presentation
how do you calculate osmolality?
2x[Na] + urea + glucose
normal osmolality range?
275-295
DKA vs HHS
HHS usually seen in older patients and type 2 rather than type 1
HHS has a higher mortality
DKA treatment vs HHS treatment?
DKA = insulin HHS = diet/OHA/insulin (sometimes)
how is alcohol induced ketoacidosis managed?
IV pabrinex IV fluids IV anti-emetics insulin may be needed on occasion address alcohol dependency
biochemical features of alcoholic/starvation ketoacidosis?
dehydration
ketonaemia >3 or significant ketonuria >2
bicarbonate <15 or venous pH <7.3
normal glucose
3 main characteristics of alcohol-induced ketoacidosis?
acetate
acetoacetate
beta-OHB