Diabetic emergencies Flashcards
Role of insulin
- Transports glucose into muscle, adipose and liver
- Inhibits lipolysis
- ANABOLIC
What happens in absence of insulin?
- Glucose accumulates in blood
- Liver uses amino acids for gluconeogenesis and converts fatty acids into ketone bodies
Ketone bodies examples
- Acetone
- Acetoacetate
- B-hydroxybutyrate
Precipitating factors for DKA
- Failure to take insulin - most common
- Failure to increase insulin
- Illness/infection - pneumonia, MI, stroke
- Acute stress - trauma, emotional
- Medical stress - counterregulatory hormones oppose insulin and stimulate glucagon release
- Hypovolaemia - increase catacholamines and glucagon, decreased renal blood flow so decreased glucagon degradation by kidneys
DKA presentation
- Polyuria, polydipsia
- Dehydration - tachycardia, orthostatic hypotension
- Abdominal pain - N+V
- Fruity breath - acetone
- Mental state changes - agitation, drunk like state, coma
DKA biochemical criteria
Diabetic:
* Hyperglycaemia BG more than 11mmol/L
Keto:
* Ketonaemia more than 3mmol/L or ketouria
Acidosis:
* Raised anion gap acidosis (more than 12)
* pH less than 7.3
When is glucose sometimes normal in DKA?
- Pregnancy
Treatment of DKA - aims
- Reduce ketones by 0.5/hr
- Increase HCO3 by 3/hr
- Reduce glucose by 3/hr
- Maintain K+ between 4.5-5.5mmol/L (insulin causes hypokalaemia)
Initial assessment for DKA
- Fluid resucitation - 1st
- Clinical exam
- Investigation to find cause - VBG, U&E, FBC, ECG, CXR, MCU
- Cardiac monitoring
Prophylaxis for DKA
LMWH - hypercoagulable state
Management of DKA
- Fluid resucitation
- Potassium replacement
- Fixed rate insulin infusion
- Continious monitoring
Fluid resucitation in DKA
- 0.9% saline 1L over 1hr
- Then 1L over 2hrs, and another of these
- Then 1L over 4 hours and another of these
Be more cautious in fluid overload eg CHF
When to check blood gas to check K+ and pH DKA?
- Every time change fluid bag
- So at 1hr, then 2hr, then 2hr, then 4hr then 4hr
Potassium replacement guide for DKA
- If K+ is more than 5.5 - no replacement
- If 3.5-5.5 give 40mmol/L
- If less than 3.5 - additional K+ is needed, consider ITU/HDU
Insulin infusion regime for DKA
- Fixed rate insulin infusion of 0.1unit/kg/hr
- eg 50 units of Actrapid in 50ml 0.9% saline)
When to cheeck potassium and glucose DKA?
Every hour
What does continious monitoring involve in DKA?
- Ensure metabolic targets in aims are achieved
- Treat underlying cause
- NG tube or catheter if needed
- Monitor urine output
Risks with DKA treatment
- Hypoglycaemia - if happens continue insulin but give dextrose
- Pulmonary oedema - give diuretic
When is DKA defined as resolved?
- Ketones less than 0.6mmol/L
- Bicarbonate more than 15mmol/L
- pH more than 7.3
- Ketonaemia and acidosis should resolve within 24hrs - if not need to consult endo
What to do once DKA resolved?
- Move to sliding scale/variable regime for overnight/few hours
- Then re-start previous regime or calculate new if new presentation
- Most adults need 0.5 units/kg/day
- Adolescents or high insulin resisatnce 0.8-1 units/kg/day
- 50% long acting and 50% short acting
- Short acting split between 3 meals
Complications of DKA
- Infection - precipitates DKA, leukocytosis can be secondary to acidosis
- Shock - if no improvement with fluids
- Vascular thrombosis - dehydration, cerebral vessels, hours to days after DKA
- Pulmonary oedema
- Cerebral oedema
Cerebral oedema manageemtn
- Occurs within 24hrs of treatment
- Mental status changes
- Mannitol
- May need intubation and ventilation
Who does hyperosmolar hyperglycaemic state often happen in?
T2DM elderly pts
Why is mortality higher in HHS than DKA?
- Happens in eldery
- Decreased physiological reserve
- Mortality higher maybe due to underlying cause precipitating HHS rather than itself
What is HHS?
- Extreme hyperglycaemia and dehydration
- Unable to excrete glucose as fast as it enters extracellular space
- Hyperglycaemia leads to osmotic diuresis and loss of water (more than electrolytes)
Criteria for HHS
- Hypovolaemia
- Hyperglycaemia - 30mmol/L or more
- No significant ketonaemia (less than 3 or acidosis pH more than 7.3, HCO3 more than 15mmol/L)
- High osmolality (more than 320mmol/kg, normal 275-295)
Who are at risk of HHS?
Elderly patients with illness
Impaired ability to ingest fluids
Presentation of HHS
- Decreased urine output
- Elevated glucose
- CNS dysfunction
- Sometimes mixed picture with DKA - treat as if DKA
Treatment aims for HHS
- Normalise osmolality and glucose
- Replace fluid and electrolyte losses
- Reduce osmolality by 3/hr
- Reduce glucose by 3-5/hr
- Achieve +ve fluid balance of 3-6 litres by 12 hours, remaining should be within 12hrs
- Complete normalisation may take up to 72hrs
Initial assessment HHS
- Fluid resuciation
- Clinical exam
- Investigation - VBG, U&E, FBC, ECG, CXR, MSU - find cause
- Cardiac monitoring
Prophylaxis for HHS
LMWH - increased risk of VTE
Fluids in HHS
IV 0.9% saline 1L over 1hr
Consider more rapid if systolic is below 90
When to caution with fluid treatment in HHS?
- Elderly - rapid replacement may precipitate HF
- But insufficient can lead to acute kidney injury
When to use insulin in HHS?
No unless:
* Significant ketonaemia (more than 1mmol/L)
* OR ketonuria of 2 or more
* RATE is slower infusion at 0.05 units/kg/hr
Main treatment for HHS?
FLUIDS - normalise osmolality
Mechanisms of hypoglycaemia
- Medication induced
- Starvation
- Insulinoma
- Reactive hypoglycaemia - mismatch between body insulin production and food
Risk factors for hypoglycaemia
- Old age
- Malnutrition
- Acute illness
- Hypoglycaemia unawareness
- Dementia
- LOTS
What is hypoglycaemia unawareness?
- Pts who have good control of diabetes eg between 4-5 usually
- Body stops producing symptoms when hypoglycaemia occurs
- Get silent hypoglycaemia
- Can then suddenly get syncope
- Often need CGM and alarm when drops
What level is hypoglycaemia?
Less than 4mmol/L
Usually 2-4 get sympathetic symptoms
Less than 2 get neurological symptoms
Emergency treatment for conscious patient with hypoglycaemia
- 1 glass lucozade (120mls)
- 150-200mls pure fruit juice
- 3 dextrosol tablets
- 1 tube glucose ge;
- 60mls fortijuice
Treatment may need repeating 5-10 mins after if no improvement
If remains less 4 after 3 attempts or 45 minutes condier glucagon or IV glucose
Emergency treatment for patient who is confused/disorientated and unable to tolerate oral treatment hypoglycaemia
- Glucagon - 1mg with dilutents IM
If patient remains uncoperative, usually respond within 10 mins
N+V can occur post dose
If no response (still less than 4) use IV glucose regime
Steps to follow if patient unconscious, fitting and unable to swallow
- DO regime for unconcious patient as mentioned in previous card
- Also check ABC
- Stop any IV insulin
- 10% glucose infusion 200ms over 10 mins
- OR 20% glucose 100mls stat
Usually responds within 4-6 mins
Always check glucose levels 10-15 mins after initial treatment and at 1 hr
Management of hypoglycaemia on recovery
Longer acting carbohydrate or next meal if due eg:
* sandwhich
* 2 digestives
* 1 slice toast
* non sugary cereals
* 200-300mls milk
