Diabetic emergencies Flashcards
Define what Diabetic ketoacidosis (DKA) is
DKA is a disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones i.e. glucagon, adrenaline, cortisol and growth hormone.
Can DKA occur in both T1DM and T2DM?
Yes - but much more common in T1DM
What is most patients who develop DKA’s, glycaemia control like?
They usually have poor gylcaemic control
What is the biochemical facotors used to dianose DKA?
- Ketonaemia > 3mmol /L, or significant ketonuria (>2+ on standard urine stick)
- Blood glucose > 11.0 mmol /L or known diabetes (NB euglycaemic DKA)
- Bicarbonate < 15 mmol /L or venous pH < 7.3
Describe the pathophysiology of DKA
List some of the factors which predispose patients to DKA?
- Infection (20 to 25%) – may be an over-estimate
- Illicit drugs and alcohol (10 to 15%)
- Non-adherence with treatment (45 to 50%) – may be under-estimate
- Newly diagnosed diabetes (25%)
What ages is DKA usually seen in ?
Young people but can be older
What are the typical symptoms of DKA?
Osmotic related:
- Thirst and polyuria
- Dehydration
Ketone body related:
- Flushed
- Vomiting
- Abdominal pain and tenderness
- Breathless – Kussmaul’s respiration
- Note - not all individuals can smell ketones on breath
List a couple conditions associated with DKA
- Underlying sepsis
- Gastroenteritis
List the rest of the biochemical results which suggest DKA
Glucose
- Median level around 40 mmol/L - [Normal<6]P
Potassium
- Usually raised above 5.5 mmol/L (complications arise due to low K so i think its actually usually low)
Creatinine: often raised
Sodium: often reduced
Raised lactate is very common
Blood ketones usually raised to > 5
- Blood measure is βhydroxybutarate
- Urine is acetoacetate
Bicarbonate: <10 in most severe cases
Amylase very frequently raised – does not necessarily mean pancreatitis [can be salivary in origin]
White cell count
- Median around 25
- Does not always infer infection
Give examples of some of the complications of DKA
- Low K – cardiac arrest and death
- Brain swelling another complication
- Gastric diliatation
- ARDS
- Aspiration pneumonia
How is DKA treated ?
Fluid: (oral if alert, IV if unconscious)
- Initially with 0.9% sodium chloride
- Glucose falls to about 15, switch to dextrose
Give insulin (oral if alert, IV if unconscious)
Potassium replacement if needed
Phosphate is rarley replaced and bicarbonate is almost never replaced
What monitoring tests are done for patients with DKA?
Potassium levels monitored
Source sepsis: CXR, Blood Culture, MSSU +/- viral titres, etc.
Prescribe prophylactic LMWH (low molecular weight heparin)
What are the symptoms of diabetes
What are the typical features of HHS (hyperglycaemic hyperosmolar syndrome)?
- General: fatigue, lethargy, nausea and vomiting
- Neurological: altered level of consciousness, headaches, papilloedema, weakness
- Haematological: hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)
- Cardiovascular: dehydration, hypotension, tachycardia
- Usually older individuals with T2DM
- High refined CHO intake pre-event
List some of the factors which can predispose patients to HHS
- Cardiovascular event [stroke or MI]
- Sepsis
- Medications: Glucocorticoids and thiazide diuretics.
What is the typical biochemistry in HHS?
- Higher glucose than in DKA -Median around 60
- Significant renal impairment (high creatinine?, low GFR?)
- Sodium may be raised
- Significant elevation of osmolality – often around 400 (norm is around 285-29). Osmolality=2x[Na+K] + Urea + Glucose
- Less ketonaemic/acidotic as compared to DKA
How is HHS diagnosed ?
- Hypovolaemia
- Marked hyperglycaemia >30mmol/L (without significant ketonaemia or acidosis)
- Osmolality >320mmol/L
What are the principles of management of patients with HHS?
- Monitor BG, sodium and osmolality every 1-2 hrs to monitor progress
- Assess severity of dehydration and give 0.9% saline (+/- K+) for fluid replacement WITHOUT insulin. This alone will lower BG which will reduce osmolality
- Start low dose IV insulin (0.05units/kg/hr) if significant ketonaemia or ketonuria present or BG falling at rate lower than 5mmol/hr despite adequate fluid replacement therapy
- Commence prophylactic anticoagulation
- All at risk of foot ulcers so check regularly and prevent
Compare HHS and DKA ?
Also LMWH is always given in HHS unless contra-indicated this is not the case in DKA
Where does lactate originate from and what is it the product of ?
Product of anaerobic metabolism of glucose and originates from red cells, skeletal muscle, brain and renal medulla
How is lactate cleared ?
Taken up by the liver and converted into pyruvate then glucose by aerobic conversion
What is the normal range of lactate ?
0.6-1.2 mmol/L
What can be a cause of a very high lactate ?
Severe exercise
