Diabetes (Slide Deck 6) Flashcards
What is the definition of Hypoglycemia?
- Low BG level (< 4.0 mmol/L);
- Development of autonomic (adrenergic) or neuroglycopenic (CNS) symptoms; and
- Symptoms respond to the intake of carbohydrates
Common causes or risk factors of Hypoglycemia
- Not eating on time (missed meals), not eating enough
- Unusual amount (excessive) of physical exercise
- Taking too much of an anti-hyperglycemic medication
- Alcohol
- Prior episode of severe hypoglycemia; hypoglycemia unawareness
What are the Neurogenic (Autonomic) forms of hypoglycemia?
- Usually occurs first, at a BG level < 4.0 mmol/L
- Symptoms:trembling, palpitations, sweating, anxiety, hunger, nausea, tingling
What are the Neuroglycopenic symptoms of hypoglycemia?
- Usually occurs when BG level < 2.8 mmol/L
- Symptoms: difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness
What are the glucose levels of Mild, Moderate and Severe hypoglycemia?
Mild: Glucose < 3.9 mmol/L
Moderate: Glucose < 3.0 mmol/L USA
Severe: Glucose usually <2.8 mmol/L USA
Major risk factors of Hypoglycemia
in T1DM
- Prior episode of severe hypoglycemia
- Current low glycated A1C (< 6.0 %)
- Hypoglycemia Unawareness
- Long duration of diabetes
- Autonomic neuropathy
- Adolescence
- Preschool-aged children unable to
detect and/or treat mild hypoglycemia on their own
Major risk factors of Hypoglycemia in T2DM
- Advancing age
- Severe cognitive impairment
- Poor health literacy
- Food insecurity
- Increased A1C
- Hypoglycemia unawareness
- Duration of insulin therapy
- Renal impairment
- Neuropathy
What are the steps to address Hypoglycemia?
- Recognize autonomic or neuroglycopenic symptoms
- Confirm if possible (with CBG, FGM, CGM)
- Treat with “fast sugar” to relieve symptoms
- Retest in 15 minutes to ensure that BG > 4.0 mmol/L and retreat if needed
- Eat usual snack or meal due at that time of the day* or a snack with 15 g carbohydrate plus protein
What is the treatment steps of severe hypoglycemia? (Conscious)
- Treat with with oral ingestion of 20 g carbohydrate,
preferably as glucose tabs
* This will raise BG by ~ 3.5 mmol/L over 45 mins - Wait 15 mins and retest BG
- Retreat with another 15 g of glucose if the BG level remains < 4.0 mmol/L
- Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
What is the treatment steps of severe hypoglycemia (Unconscious)
- Treat with glucagon
(1 mg IM or IV or 3mg nasal spray)
* E.g. GlucaGen® Hypokit, Glucagon®, Baqsimi®)
* Triggers the liver to release stored sugar - Call 911
- Turn the patient into recovery position
- Eat as soon as safely possible
- Discuss with health care team
What is Pseudo-hypoglycemia
A state in which an individual experiences symptoms of hypoglycemia despite having BG levels > 4.0 mmol/L
This usually occurs to people who have chronically high BG and have a rapid drop in BG levels
What are the usual causes of hyperglycemia?
- Too little / omission of insulin
- Illness (UTI, sepsis, pneumonia are common culprits of DKA) – see an increase in counter-regulatory hormones
- Infection
- Surgery
- Injury
- Stress; emotional or physical
- Increased food
- Exercise (in T1DM) with BG > 14 mmol/L and ketones
What is DKA?
DKA occurs as a result of insulin deficiency and is characterized
- Hyperglycemia (usually >14 mmol/L) Is serious!
- Ketonemia
- Metabolic acidosis (venous pH <7.3 and/or serum bicarbonate <15mmol/L, anion gap >12 mmol/L)
What does insulin deficiency lead to
Loss of water and electrolytes such as NA, K, Cl
ALSO
Stimulates lipolysis
What does insulin deficiency lead to
Loss of water and electrolytes such as NA, K, Cl
ALSO
Stimulates lipolysis
What is lipolysis?
breakdown of TGs into FFAs that are converted into ketone bodies by the liver and released into circulation; this causes acidosis
What are the symptoms of acidosis?
Abdominal pain
Air Hunger
Fruity acetone breath
Hyperventilation
Confusion
What is the general treatment protocol for metabolic acidosis?
Replace Fluids
Correct Potassium
Correct acidosis
Correct BG
What is Hyperosmolar hyperglycemic syndrome?
Characterized by extremely high sugar, increased osmolality, significant dehydration, and minimal ketoacidosis
Generally in older patients with T2DM
What is the main difference between DKA and HHS?
Ketogenesis does not occur in HHS
What is the general protocol for resolving HHS?
Fluids
Restore K
Insulin
Search for precipitating causes
What can be done to prevent DKA/HHS?
- Education around sick day management
- Adjust insulin dose as needed; continuation of
insulin even when not eating - Frequent monitoring of BG when ill * Check for ketones
What is the main difference in blood glucose between DKA/HHS
DKA = >14mmol
HHS= >34mmol
What is the normal range for blood glucose?
4.0-8.0mmol/l
