Diabetes (Metabolic Complications)

Question 1

What are the two major hyperglycaemic complications of diabetes?

Answer 1

Hyperglycaemic Hyperosmolar State

Diabetic Ketoacidosis

Question 2

What is Hyperglycaemic Hyperosmolar State?

Answer 2

Severe hyperglycaemia with marked serum hyperosmolarity without evidence of significant ketosis

Question 3

What is Diabetic Ketoacidosis?

Answer 3

Hyperglycaemia and acidosis caused by excessive ketones

Question 4

What metabolic pathways underlie DKA?

Answer 4

Absence of Insulin causes hepatic glucose production/reduced peripheral uptake
Osmotic diuresis leads to dehydration
Lipolysis produces FFA –> Ketones
Ketones cause metabolic acidosis

Question 5

What effect does the DKA have on the body?

Answer 5

Vomiting/electrolyte loss
Resp - Hyperventilation
Renal - Perfusion falls, impaired excretion of H+/ketones, Na/K loss

Question 6

What is the effect on DKA on K levels?

Answer 6

Increased excretion of K
Initial serum K+ normal/elevated (pseudo-hyperkalaemia)
Due to extracellular migration of K+
Life threatening hypokalaemia may develop

Question 7

What are the common causes of DKA?

Answer 7

Prev undiagnosed DM
Interruption of insulin therapy
Intercurrent illness/sugery

Question 8

How does DKA present?

Answer 8

Prostration
Kussmal resp (air hunger)
N/V
Abdo pain
Confusion/stupor

Question 9

What are the three key diagnostic criteria required for a diagnosis of DKA?

Answer 9

Acidaemia (pH <7.35) OR vHCO3- <15mmol/L
Hyperglycaemia (>11.1mmol/L) OR prev known DM
Ketonaemia - >3mmol/L OR >2+ in urine

Question 10

What investigations are appropriated in suspected DKA?

Answer 10

U&Es, creatinine, BM
VBG (metabolic acidosis w/ raised anion gap)
ECG/CXR/cultures/preg test (clinical suspicion)

Question 11

What determines the severity of DKA?

Answer 11

Blood pH

• Mild <7.3
• Mod 7.1-7.3
• Sev <7.1

Question 12

What is the immediate management of DKA?

Answer 12

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

Question 13

When should an urgent critical care review be sought?

Answer 13

Severe DKA
Drowsy
Pregnant
Sats <94% on 40% O2
Persistent hypotension (SBP <90 after 2L NaCl)

Question 14

What non-immediate management should be considered in DKA?

Answer 14

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

Question 15

What management should be considered in DKA, once the pt is stable?

Answer 15

Transfer to SC insulin
Stop IV infusion
Refer to DM team

Question 16

What is Hyperosmolar Hyperglycaemic State?

Answer 16

Severe hyperglycaemia causing a hyperosmolar state, in the absence of severe ketosis

Question 17

In which groups does HHS occur?

Answer 17

T2DM

Elderly

Question 18

What are the precipitating factors for HHS?

Answer 18

Consumption of G6 rich foods
Medications - Thiazides, steroids, b-blockers
Infection
MI

Question 19

How does HHS present?

Answer 19

Dehydration
Stupor/coma/seizures
Evidence of underlying illness

Question 20

How is a diagnosis of HHS confirmed?

Answer 20

Osmolality >320

-normal 280-295

Question 21

What is the immediate management of HHS?

Answer 21

IV NaCl (3-6L/12hrs)
Low dose, fixed dose IV Insulin
K+ replacement
Prophylactic LMWH

Question 22

How is HHS managed once the pt is stable?

Answer 22

Monitor - Vitals, fluids, glucose, osmolality, U&Es (hrly)
SC insulin
Refer to DM team

Question 23

What is Hypoglycaemia?

Answer 23

Plasma glucose <3mmol/L

Question 24

What are the two broad classifications of sx caused by Hypoglycaemia?

Answer 24

Autonomic

Neuroglycopenic

Question 25

What are the autonomic sx of Hypoglycaemia?

Answer 25

Sweating
Anxiety
Hunger
Tremor
Palpitations

Question 26

What are the neuroglycopenic sx of Hypoglycaemia?

Answer 26

Confusion
Drowsiness/Coma
Seizures

Question 27

What hormone does the pancreas release in response to Hypoglycaemia?

Answer 27

Glucagon

Question 28

What are the effects of Glucagon?

Answer 28

Increase glycogenolysis
Increase gluconeogenesis
Inhibit glycogen synthesis

Question 29

What about T1DM predisposes pts to Hypoglycaemia?

Answer 29

Insulin overdoses

a cells insensitive to falls in glucose, no glucagon released

Question 30

What are the causes of Hypoglycaemia?

Answer 30

Excess Insulin - Exogenous, insulinoma
Depletion of hepatic glycogen - malnutrition, fasting, exercise, alcohol, liver failure
Pituitary/adrenal insufficiency
Non-pancreatic neoplasms

Question 31

What is the management of non-severe Hypoglycaemia?

Answer 31

10-20g of fast acting carbohydrate (preferably liquid)
Recheck blood glucose after 10-15mins
If inadequate repeat & recheck
Sx improvement may lag behind, when sx improve give
LA carbohydrate

Question 32

What is the management of severe Hypoglycaemia?

Answer 32

IM glucagon
-500mg if <8yrs
-1g if >8yrs
If pt responds give LA carbohydrate

Question 33

When is glucagon not effective?

Answer 33

If alcohol has been consumed

Question 34

What is a common complication during recovery?

Answer 34

Vomiting

Can precipitate further hypos

Question 35

What can be used in hospital as an alternative to glucagon?

Answer 35

100ml of 20% glucose

Used up to 3 times