Diabetic emergencies 1 (ignore) Flashcards
Define what DKA is
It is a disordered metabolic state that usually occurs in the context of absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones i.e. glucagon, adrenaline, cortisol and growth hormone
Describe the pathophysiology of DKA
- Absolute or relative insulin deficiency
- Stress hormone release
- Increased lipolysis, Decreased glucose utilisation, Increased proteolysis, Increased glycogenolysis
- Decreased glucose utilisation, increased proteolysis and increased glycogenolysis all contribute to result of hyperglycaemia
- Increased lipolysis ===> increased FFA’s ===> increased ketogenesis ===> Acidosis
What are the biochemical results which would diagnosis DKA?
- Ketonaemia > 3mmol/L or ketonuria > 2++
- Blood glucose > 11mmol/L
- Bicarbonate < 15 mmol/L or pH < 7.3
What are the common precipitants of DKA ?
- Infection
- Illict drugs and alcohol
- Non-adherance to treatment
- Newly diagnosed diabetes (less likely to have the diabetes under control)
What are the typical signs/symptoms of DKA and HHS in general ?
- Polyuria
- Polydipsia (thirst)
- Weight loss
- Weakness
- Tachycardia
- Hypotension
- Gradual drowsiness
What are the symptoms more specific to DKA rather than HHS ?
- Flushed
- Abdominal pain and tenderness
- Breathless - kaussmuals breathing (deep and laboured)
What is the classic full biochem results of DKA ?
Include:
- Glucose
- Potassium
- Creatinine
- Sodium
- Lactate
- Amylase
- Glucose - median is 40 mmol/L
- Potassium - usually raised > 5.5 mmol/L
- Creatinine - often raised
- Sodium - often raised
- Lactate - very commonly raised
- Amylase - frequently raised
What are the main causes of death in-relation to DKA?
- Adults - hypokalaemia, Aspiration pneumonia, ARDS, co-morbidities
- Children - cerebral oedema
What is the management of DKA ?
- Give fluids - saline solution
- Give IV insulin 6 units/hr
- Check pH, bicarb, glucose and K+, 1hr, 2hr and then every 2hrs after treatment
When glucose < 14, give glucose to run alongside saline to prevent hypoglycaemia and reduce insulin to 3 units/hr
If K+ is low i.e. < 5.5 mmol/L then give K+ replacement when treating them
Define what hyperglycaemic hyperosmolar syndrome is
It is due to a relative or absolute insulin deficiency combined with increased counter-regulatory hormones just like DKA
It is characterised by profound hyperglycaemia (glucose > 33), hyperosmolality (serum osmolality ≥ 320), and the absence of significant ketoacidosis
More common in T2DM
What are the key symptom of HHS ?
Dehydration
What is the typical biochemistry of HHS ?
- Higher glucose than in DKA - median around 60 mmol/L
- Significant renal impairment
- Na+ raised
- Significant elevation of osmolalty - often around 400
- Less ketoanaemic/acidotic than DKA
What are some potential causes of HHS ?
- Cardiovascular event (stroke or MI)
- Sepsis
- Medications - glucocorticoids, thiazide diuretics
- Bowel infarct
How is osmolality calculated ?
Osmolality = 2 x [Na+ + K+] + urea + glucose
Compare DKA to HHS
