Diabetes (Metabolic Complications) Flashcards
What are the two major hyperglycaemic complications of diabetes?
Hyperglycaemic Hyperosmolar State
Diabetic Ketoacidosis
What is Hyperglycaemic Hyperosmolar State?
Severe hyperglycaemia with marked serum hyperosmolarity without evidence of significant ketosis
What is Diabetic Ketoacidosis?
Hyperglycaemia and acidosis caused by excessive ketones
What metabolic pathways underlie DKA?
Absence of Insulin causes hepatic glucose production/reduced peripheral uptake
Osmotic diuresis leads to dehydration
Lipolysis produces FFA –> Ketones
Ketones cause metabolic acidosis
What effect does the DKA have on the body?
Vomiting/electrolyte loss
Resp - Hyperventilation
Renal - Perfusion falls, impaired excretion of H+/ketones, Na/K loss
What is the effect on DKA on K levels?
Increased excretion of K
Initial serum K+ normal/elevated (pseudo-hyperkalaemia)
Due to extracellular migration of K+
Life threatening hypokalaemia may develop
What are the common causes of DKA?
Prev undiagnosed DM
Interruption of insulin therapy
Intercurrent illness/sugery
How does DKA present?
Prostration Kussmal resp (air hunger) N/V Abdo pain Confusion/stupor
What are the three key diagnostic criteria required for a diagnosis of DKA?
Acidaemia (pH <7.35) OR vHCO3- <15mmol/L
Hyperglycaemia (>11.1mmol/L) OR prev known DM
Ketonaemia - >3mmol/L OR >2+ in urine
What investigations are appropriated in suspected DKA?
U&Es, creatinine, BM
VBG (metabolic acidosis w/ raised anion gap)
ECG/CXR/cultures/preg test (clinical suspicion)
What determines the severity of DKA?
Blood pH
- Mild <7.3
- Mod 7.1-7.3
- Sev <7.1
What is the immediate management of DKA?
ABCDE
1L 0.9% NaCl over 10mins if SBP >90 (500ml if <90)
IV insulin
-50 units ACTRAPID in 50ml 0.9% NaCl
-Start in syringe driver at 0.1 units/kg/hr
When should an urgent critical care review be sought?
Severe DKA Drowsy Pregnant Sats <94% on 40% O2 Persistent hypotension (SBP <90 after 2L NaCl)
What non-immediate management should be considered in DKA?
Fixed rate insulin (0.1 units/kg/hr) + LA insulin
-aim BM fall of >3mmol/L/hr until <14mmol/L
Continue 0.9% NaCl
When BM <14mmol/L add 10% glucose (125mls/hr
If plasma K <5.4 add 40mmol KCL to 1L NaCl
Reassess every 4-6hrs
What management should be considered in DKA, once the pt is stable?
Transfer to SC insulin
Stop IV infusion
Refer to DM team
What is Hyperosmolar Hyperglycaemic State?
Severe hyperglycaemia causing a hyperosmolar state, in the absence of severe ketosis
In which groups does HHS occur?
T2DM
Elderly
What are the precipitating factors for HHS?
Consumption of G6 rich foods
Medications - Thiazides, steroids, b-blockers
Infection
MI
How does HHS present?
Dehydration
Stupor/coma/seizures
Evidence of underlying illness
How is a diagnosis of HHS confirmed?
Osmolality >320
-normal 280-295
What is the immediate management of HHS?
IV NaCl (3-6L/12hrs)
Low dose, fixed dose IV Insulin
K+ replacement
Prophylactic LMWH
How is HHS managed once the pt is stable?
Monitor - Vitals, fluids, glucose, osmolality, U&Es (hrly)
SC insulin
Refer to DM team
What is Hypoglycaemia?
Plasma glucose <3mmol/L
What are the two broad classifications of sx caused by Hypoglycaemia?
Autonomic
Neuroglycopenic
