Diabetes Emergencies Flashcards
Diabetic emergencies (4)
Diabetic ketoacidosis (DKA) Hyperglycaemia Hyperosmolar Syndrome (HHS) Alcohol/ Starvation Ketoacidosis Lactate Acidosis
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
DKA Pathophysiology
Absolute insulin deficiency Hyperglycaemia Fat breakdown Ketones formed Dehydration from hyperglycaemia Osmotic diuresis
DKA at risk patients
Mainly T1Dm
Acute illness (e.g. infection) –> stress hormones
Omission/ inadequate insulin/ pump failure
DKA Presentation onset
Acute (hours)
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
Mortality in DKA (causes of death)
Adults
- Hypokalaemia
- Aspiration pneumonia
- ARDS
- Co-morbidities
Children
-Cerebral oedema
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)
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
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
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
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
Blood Ketone Testing
Measures beta-hydroxy butyrate
meter range 0-8 mmol/L
<0.6mmol/L. is normal
Preferred ketone test
Urine ketone testing
Measure acetoacetate
Indicates levels of ketones
Ketonuria persists after clinical improvement due to mobilisation of ketones from fat tissue
HHS
hyperglycaemia hyperosmolar syndrome
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
