Diabetic emergencies Flashcards
1
Q
Role of insulin
A
- Transports glucose into muscle, adipose and liver
- Inhibits lipolysis
- ANABOLIC
2
Q
What happens in absence of insulin?
A
- Glucose accumulates in blood
- Liver uses amino acids for gluconeogenesis and converts fatty acids into ketone bodies
3
Q
Ketone bodies examples
A
- Acetone
- Acetoacetate
- B-hydroxybutyrate
4
Q
Precipitating factors for DKA
A
- 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
5
Q
DKA presentation
A
- Polyuria, polydipsia
- Dehydration - tachycardia, orthostatic hypotension
- Abdominal pain - N+V
- Fruity breath - acetone
- Mental state changes - agitation, drunk like state, coma
6
Q
DKA biochemical criteria
A
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
7
Q
When is glucose sometimes normal in DKA?
A
- Pregnancy
8
Q
Treatment of DKA - aims
A
- 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)
9
Q
Initial assessment for DKA
A
- Fluid resucitation - 1st
- Clinical exam
- Investigation to find cause - VBG, U&E, FBC, ECG, CXR, MCU
- Cardiac monitoring
10
Q
Prophylaxis for DKA
A
LMWH - hypercoagulable state
11
Q
Management of DKA
A
- Fluid resucitation
- Potassium replacement
- Fixed rate insulin infusion
- Continious monitoring
12
Q
Fluid resucitation in DKA
A
- 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
13
Q
When to check blood gas to check K+ and pH DKA?
A
- Every time change fluid bag
- So at 1hr, then 2hr, then 2hr, then 4hr then 4hr
14
Q
Potassium replacement guide for DKA
A
- 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
15
Q
Insulin infusion regime for DKA
A
- Fixed rate insulin infusion of 0.1unit/kg/hr
- eg 50 units of Actrapid in 50ml 0.9% saline)
16
Q
When to cheeck potassium and glucose DKA?
A
Every hour
17
Q
What does continious monitoring involve in DKA?
A
- Ensure metabolic targets in aims are achieved
- Treat underlying cause
- NG tube or catheter if needed
- Monitor urine output
18
Q
Risks with DKA treatment
A
- Hypoglycaemia - if happens continue insulin but give dextrose
- Pulmonary oedema - give diuretic
19
Q
When is DKA defined as resolved?
A
- 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
20
Q
What to do once DKA resolved?
A
- 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
21
Q
Complications of DKA
A
- 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
22
Q
Cerebral oedema manageemtn
A
- Occurs within 24hrs of treatment
- Mental status changes
- Mannitol
- May need intubation and ventilation
23
Q
Who does hyperosmolar hyperglycaemic state often happen in?
A
T2DM elderly pts
24
Q
Why is mortality higher in HHS than DKA?
A
- Happens in eldery
- Decreased physiological reserve
- Mortality higher maybe due to underlying cause precipitating HHS rather than itself
25
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)
26
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)
27
Who are at risk of HHS?
Elderly patients with illness
Impaired ability to ingest fluids
28
Presentation of HHS
* Decreased urine output
* Elevated glucose
* CNS dysfunction
* Sometimes mixed picture with DKA - treat as if DKA
29
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
30
Initial assessment HHS
* Fluid resuciation
* Clinical exam
* Investigation - VBG, U&E, FBC, ECG, CXR, MSU - find cause
* Cardiac monitoring
31
Prophylaxis for HHS
LMWH - increased risk of VTE
32
Fluids in HHS
IV 0.9% saline 1L over 1hr
Consider more rapid if systolic is below 90
33
When to caution with fluid treatment in HHS?
* Elderly - rapid replacement may precipitate HF
* But insufficient can lead to acute kidney injury
34
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
35
Main treatment for HHS?
FLUIDS - normalise osmolality
36
Mechanisms of hypoglycaemia
* Medication induced
* Starvation
* Insulinoma
* Reactive hypoglycaemia - mismatch between body insulin production and food
37
Risk factors for hypoglycaemia
* Old age
* Malnutrition
* Acute illness
* Hypoglycaemia unawareness
* Dementia
* LOTS
38
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
39
What level is hypoglycaemia?
Less than 4mmol/L
Usually 2-4 get sympathetic symptoms
Less than 2 get neurological symptoms
40
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
41
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
42
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
43
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
44
