Insulin deficiency - poor compliance/ management Increase insulin demand - Infections: pneumonia, UTI, cellulitis - Inflammation (pancreatitis, cholecystitis) - Intoxication - Infarction (acute MI, stroke) - Iatrogenic (steroids, surgery)

IV Fluid resuscitation 1. 1000ml NaCl 0.9% in first hour 2. 2000ml NaCl by end of 2nd hour 3. 3000ml NaCl by end of 4th hour Monitoring 4. Blood for U&Es and bicarb level (2nd hr) 5. Blood for U&Es and bicarb level (4th hr) 6. IV potassium replacement Insulin 7. 'Usual' subcutaneous basal insulin given daily

Diabetes Emergencies Flashcards by Isla Carter

Diabetic emergencies (4)

Diabetic ketoacidosis (DKA)
Hyperglycaemia Hyperosmolar Syndrome (HHS) 
Alcohol/ Starvation Ketoacidosis 
Lactate Acidosis

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Diabetic Ketoacidosis

Disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones (i.e. glucagon, adrenaline, cortisol, GH)

Can occur in T1DM and T2DM

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DKA Pathophysiology

Absolute insulin deficiency 
Hyperglycaemia 
Fat breakdown 
Ketones formed
Dehydration from hyperglycaemia 
Osmotic diuresis

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DKA at risk patients

Mainly T1Dm

Acute illness (e.g. infection) –> stress hormones

Omission/ inadequate insulin/ pump failure

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DKA Presentation onset

Acute (hours)

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DKA diagnostic criteria

Blood glucose 11mmol/L or more
Venous pH <7.3 ot bicarb <15mmol/l
Blood ketones >3mmol/l
Urine Ketones 2+ or more

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Mortality in DKA (causes of death)

Adults

Hypokalaemia
Aspiration pneumonia
ARDS
Co-morbidities

Children
-Cerebral oedema

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Precipitants of DKA

Insulin deficiency
- poor compliance/ management

Increase insulin demand

Infections: pneumonia, UTI, cellulitis
Inflammation (pancreatitis, cholecystitis)
Intoxication
Infarction (acute MI, stroke)
Iatrogenic (steroids, surgery)

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DKA typical symptoms and signs

Osmotic related

thirst and polyuria
dehydration

Ketone body related

flushed
vomiting
abdo pain and tenderness
Breathless: Kussmauls Respiration

Associated conditions

Underlying sepsis
Gastroenteritis

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DKA Classical Biochem

Glucose Raised (>11mol/L)
Blood ketones usually >5
Bicarb <10 in severe cases

Potassium

often raised to >5.5mmol/L
Beware low normal reading.

Creatinine
- often raised

Raised lactate is common

WWC

Median 25
Does NOT always equate to infection

Amylase often raised

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DKA management principles

Manage in HDU following hospital protocol

Replace losses

Fluid (initially with 0.9% sodium chloride. Switch to dextrose when glucose falls to ~15)
Insulin
Potassium

Address risk

Monitor K+
Prescribe prophylactic LMWH
Source sepsis

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DKA Treatment (7)

IV Fluid resuscitation

1000ml NaCl 0.9% in first hour
2000ml NaCl by end of 2nd hour
3000ml NaCl by end of 4th hour

Monitoring

Blood for U&Es and bicarb level (2nd hr)
Blood for U&Es and bicarb level (4th hr)
IV potassium replacement

Insulin
7. ‘Usual’ subcutaneous basal insulin given daily

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Blood Ketone Testing

Measures beta-hydroxy butyrate

meter range 0-8 mmol/L

<0.6mmol/L. is normal

Preferred ketone test

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Urine ketone testing

Measure acetoacetate

Indicates levels of ketones

Ketonuria persists after clinical improvement due to mobilisation of ketones from fat tissue

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HHS

hyperglycaemia hyperosmolar syndrome

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HHS at risk patients

Occurs in people with T2DM who experience very high blood glucose levels (often >40mmol/L)

T2DM undiagnosed
Older adults
Acute illness
Illness that results in reduced fluid intake
Omission/ inadequate insulin
Drugs that raise glucose levels or cause dehydration

HHS pathophysiology

Relative insulin deficiency 
Precipitating illness
Hyperglycaemia 
Little fat breakdown/ ketones 
Dehydration from hyperglycaemia 
Osmotic diuresis

HHS presentation onset

Sub-acute (can be days )

HHS diagnostic criteria

Blood glucose 30mmol/l. or above

Urine ketones sometimes present
No/mild ketonaemia <3mmol/L

Osmolarity >320

Hypovolaemia

Bicarb. 15mmol/L or venous pH .7.3

HHS typically features

Often presents in older patients or. young afro-carribeans

High refined carbohydrate pre-presentation

HHS risk associations and complications

CV disease
Sepsis 
Medication 
- steroids 
- thiazide diuretics

HHS typical biochemistry

Higher glucose than in DKA
-typically >50mmol/L

Significant renal impairment

Sodium often high normal or raised

Less ketogenic/ acidotic than in DKA

Raised Osmolarity (>320) 
- Normal: 275-295

HHS treatment

Normalise osmolarity gradually and safely

replace fluid and electrolyte. losses
normalise blood glucose

Treat. underlying cause

Assess severity of dehydration
- 0.9% saline for fluid replacement WITHOUT insulin

Monitor and chart blood glucose, osmolarity and sodium

Start low dose IV insulin ONLY if significant ketones (>1) or if Bg falling at slow rate

Identify underlying precipitants

Alcoholic/ Starvation Ketoacidosis

History is important

Dehydration is common: often marked

Alcoholic/ Starvation Ketoacidosis Biochem

Ketonaemia >3mmol/L - or significant ketonuria (>2+ on standard urine stick) Bicarb usually <15mmol/L Venous pH <7.3 in severe cases Glucose usually normal (may be low)

Lactate

Lactate is the end product of anaerobic metabolism of glucose Clearance requires hepatic uptake and aerobic conversion to. pyruvate then glucose Normal lactate range: 0.6-1.2 mmol/L Generally lactate lowest in fasted state In severe exercise lactate may rise to 10mmol/L

Lactate Acidosis Type A

Associated with tissue hyperaemia - Sepsis (endotoxic shock) - Haemorrhage

Lactic Acidosis Type B

May occur in - liver disease - Leukaemic states

MALA

Metformin associated lactic acidosis

Lactic acidosis clinical features

Hyperventilation mental confusion stupor or coma if severe

Lactic acidosis lab findings

``` Reduced bicarb Raised anion gap Glucose variable (often raised) Absence of ketonaemia Raised phophate ```

Lactate acidosis treatment

treat underlying conditions - fluid - antibiotics Withdraw offending medication