Diabetes emergencies

Question 1

What type of emergency is DKA?

Answer 1

HYPERglycaemic emergency

Question 2

What happens in DKA?

Answer 2

• (In response to the absence of insulin): increased glycogenolysis (breakdown of glycogen) and gluconeogenesis (generation of glucose) PLUS reduced glucose uptake by tissues
• Increased urine out-put (to remove glucose) = dehydration
• Suppressed lipolysis = accumulation of free fatty acids (metabolised to ketones)
• profound acidosis (pH <7.4, but often <7)
• severe dehydration

Question 3

What BGL is hyperglycaemia?

Answer 3

> 11mmol/L

Question 4

What happens to glomerular filtration rate in DKA?

Answer 4

Can increase by 50% initially, but kidneys get tired

Question 5

What are the symptoms of DKA?

Answer 5

• Tachypnoea (physiological response to acidosis)
• Altered mental state (drowsiness or coma)
• Nausea, vomiting, abdominal pain

Question 6

What is the management of DKA for the first 4 hours (adults and children)?

Answer 6

Fluid resuscitation – first hour
- Isotonic fluids only (0.9% sodium chloride, Plasmalyte)
- Given slowly (Rapid fluid replacement – cerebral oedema, coma and death)
Insulin Variable Rate Infusion(1-2hrs after fluid)
- “Sliding scale” – 0.05 to 0.1unit/kg/hr
- Monitor capillary blood glucose (cBG) HOURLY
- Once cBG <15mmol/L consider move to maintenance fluid

Question 7

What can happen if fluid resuscitation is given too rapidly?

Answer 7

Can result in cerebral oedema, coma and death

Question 8

What is the maintenance management for DKA for adults?

Answer 8

Maintenance fluid (2L/day maximum)
- Give glucose containing fluid (0.9% sodium chloride + 5% glucose) WITH potassium chloride
- Continue insulin “sliding scale”
- Titrate to ketones:
<3mmol/L – reduce insulin
>3mmol/L – give more glucose OR increase insulin
Once ready to eat and drink
- Let patient eat THEN:
Give sc insulin 30 minutes before stopping insulin
infusion THEN:
Stop glucose IV

Question 9

What is the maintenance management for DKA for children and young people?

Answer 9

Fluid restriction 50% “normal maintenance”
- 10kg = 2ml/kg/hr
- 10-40kg = 1ml/kg/hr
- >40kg = 40ml/hr (not weight based)
Replace fluid deficit (dehydration) over 48hrs
Start s/c insulin when:
- cBG <14mmol/L
- Ketones <3mmol/L
- Resolved acidosis
- Oral fluids tolerated

Question 10

What are the complications of DKA?

Answer 10

Fatality rate ranging from 0.15 percent to 0.31 percent1 in children
- Cerebral oedema (most common cause of fatality)
- 12/1000 presentations in children (mortality 24%) (Edge 2001)
- “Extremely rare” in adults (Kitabchi 2009)
- Caused by rapid movement of water into cells in the brain
- Too much fluid (>4ml/kg/hr)
- Hypotonic fluid (<0.9% sodium chloride)
Signs & Symptoms
- Bradycardia
- Dilated pupils
- Altered mental state/unconsciousness

Question 11

What is Hyperosmolar Hyperglycaemic state?

Answer 11

• In response to lack of insulin effect
• Insulin is still there so NO lipid metabolism
• Severe hyperglycaemia (BG usually >50 mmol/L) + hyperosmolality (Serum osmolality usually >350mosmol/kg)
• High blood sugars results in increased urination and dehydration
• Little to no acidosis

Question 12

What are the sick day rules?

Answer 12

• Keep taking your diabetes medications – even if you don’t feel like eating.
• Check your blood sugar more often – at least every four hours, including during the night. If you don’t test your blood sugar levels at home, be aware of the signs of a hyper (hypergylcaemia).
• Stay hydrated – have plenty of unsweetened drinks, and eat little and often.
• Check for ketones– if your blood sugar level is 15mmol/l or more, or 13mmol/l if you use an insulin pump. If ketones are present, contact your diabetes team. Checking for ketones is especially important for people with Type 1 diabetes.
• Keep eating or drinking – if you can’t keep food down, try snacks or drinks with carbohydrates in to give you energy. Try to sip sugary drinks (such as fruit juice or non-diet cola or lemonade) or suck on glucose tablets or sweets like jelly beans. Letting fizzy drinks go flat may help keep them down. If you’re vomiting, or not able to keep fluids down, get medical help as soon as possible.

Question 13

What drugs need to be stopped when someone with diabetes is unwell?

Answer 13

• ACE inhibitors (ending in pril)
• ARBs (ending in sartan)
• NSAIDs (e.g. ibuprofen, diclofenac)
• Diuretics (e.g. furosemide, spironolactone)
• Metformin

Question 14

What needs to be done when a patient is unwell, with BG over 11 mmol/L but no ketones?

Answer 14

• Check BG and urine ketone/capillary blood ketones at every meal time
• PATIENT MUST HAVE USUAL LONG ACTING INSULIN
• If patient is unable to eat (but not vomiting) they should have sugary drinks (milk/OJ) and have their usual rapid acting insulin
• give correction dose for BG levels that are outside of target range (1 units of rapid acting insulin to lower BG by 3.0 mmol/L - max correction dose is 4 units)
• If patient has small to moderate ketones step up to STEP 2
• if patient has large ketones - STEP 3

Question 15

What is step 2 when a diabetes patient is unwell, BG over 11 mmol/L, small to moderate ketones, capillary blood ketones 1.5-3mmol/L?

Answer 15

• patient MUST have their usual long acting insulin
• Give 10% of TDD (total daily dose) as rapid acting insulin
• If patient is eating they should continue usual rapid acting insulin
• check BG and test urine/capillary blood ketones every 2 hours
• when ketones have gone step down to step 1

Question 16

What is step 3 when a diabetes patient is unwell, blood glucose over 11 mmol/L, large ketones, capillary blood ketones over 3 mmol/L

Answer 16

• patient MUST have their usual long acting insulin
• give 20% of TDD as rapid acting insulin
• if patient is eating continue usual rapid acting insulin
• check BG and test urine/capillary blood ketones every 2 hours
• when ketones have gone down - go to step 2 then step 1 if reduce further

Question 17

What are the aims of treating a sick person with diabetes?

Answer 17

Initially:

• Normalise osmolality
• Replace fluids
• Balance electrolytes

Also Prevent:

• Clots due to thickened blood and slow flow
• Foot ulcers
• Cerebral oedema

Question 18

Treatment of a sick person with diabetes?

Answer 18

• Lots of physiological fluid (not just sodium chloride 0.9%) to correct blood pressure
• Target SBP >90mmHg
  Start SLOW variable rate insulin infusion (aim a rate of no faster than 5mmol/l/min
• Replace potassium as required
• Give clot preventing medication (Low molecular weight heparins)

Question 19

What is hypoglycaemia?

Answer 19

<4.0 mmol/L in people with medication controlled diabetes

Question 20

What are the symptoms of HYPOglycaemia?

Answer 20

Autonomic symptoms:
  - Tremor  	
  - Sweating
  - Hunger 		
  - Palpitations
Neuroglycopenic symptoms:
  - Odd behaviour, poor co-ordination or confusion
  - Drowsiness/loss of consciousness
  - Visual disturbance
  - Seizures 
Non-specific symptoms
  - Headache and nausea

Question 21

What needs to be done in patients with HYPOglycaemia?

Answer 21

REPLACE THE GLUCOSE:
- Short acting carbs followed by long acting carbs
At home:
- Lucozade /Sweets (other sugary drinks are available)
- Meal if due or snack such as biscuits
In hospital:
- If conscious - Dextrose tabs or Glucogel then meal if due or snack such as biscuits
- If unconscious - Glucogon IM followed by 10% glucose 100ml/hr