Diabetic Emergencies

Question 1

What are the 2 HYPERglycaemic emergencies?

Answer 1

DKA (diabetic ketoacidosis)

HHS (hyperosmolar hyperglycaemic state)

Question 2

What is the triad of DKA?

Answer 2

Hyperglycaemia
Hyperketonaemia
Metabolic Acidosis

Question 3

What is the DKA diagnostic criteria?

Answer 3

BM >11mmol/L (diabetic level) or KNOWN diabetic
Blood ketones >3mmol/L or ketonuria >2+
Bicarb <15mmol/L or venous pH <7.3

Question 4

Other than low insulin, what else can cause increased ketone production and therefore DKA?

Answer 4

Increase stress hormones (cortisol, catecholamines) which also promote the ketone pathway

Question 5

What is the role of insulin with respect to potassium?

How does this affect DKA?

Answer 5

Insulin causes potassium to move INTO cells

In DKA in T1DM patients, the lack of insulin causes K leak from cells causing a high extracellular K (hyperkalaemia)

This causes K loss via urine = whole body K depletion

Question 6

Why in DKA treatment is it important to think about K?

Answer 6

When DKA is treated K moves into the cells quickly from the plasma, and with total body K depletion this means K levels in plasma fall quickly

Arrhythmias can therefore occur

Question 7

Why can cerebral oedema, PE and ARDS occur in DKA?

Answer 7

Fluid shifts

Question 8

What are breathing signs of DKA?

Why does this occur?

Answer 8

Kussmaul breathing = deep, sighing breaths

To respiratory compensate for acidosis by removing CO2 from the body

Question 9

What are the principles and steps of treatment of DKA?

Answer 9

Fluid replacement (helps acid/base balance)
Insulin replacement
Potassium replacement as fluids + insulin will cause K shift into cells
Indemnify and treat cause (?infection)
VTE prophylaxis

Question 10

What is the insulin treatment dose for DKA?

Answer 10

0.1unit/kg/hr

Question 11

Which fluid do you use as replacement in DKA?

Answer 11

0.9% sodium chloride

Question 12

In which patient groups is DKA most likely seen?

What about HHS?

Answer 12

DKA = T1DM patients

HHS = T2DM patients, as enough insulin production to suppress ketogenesis

Question 13

What is the clinical definition/diagnosis of HHS?

Answer 13

No precise definition

• hypovolaemia (due to osmotic diuresis)
• hyperglycaemia >30mmol/L!!!!!
• hyperosmolarity of serum >320mosm/kg

KEY FACTOR:
- ketones <3mmol/L, no acidosis (pH>7.3) and bicarb >15mmol/L

Question 14

Which condition has greater mortality risks and why, DKA or HHS?

Answer 14

HHS as metabolic disturbance is greater

Question 15

Compare the DKA and HHS onset times?

Answer 15

HHS happens over days, DKA is quicker

Question 16

How would you calculate the osmolarity from a blood gas?

Answer 16

(2 X Na) + glucose + urea

Question 17

How does HHS treatment differ from DKA?

Answer 17

Slow replacement of fluids

Lower insulin infusion (0.05units/kg/hr)

Question 18

What are the main differences in measurements (values) seem between DKA and HHS?

Answer 18

DKA = ketones high = low pH and low bicarb, GLUCOSE >11mmol/L

HHS = ketones normal (or just raised), pH normal, bicarb normal, GLUCOSE&raquo_space;30mmol/L!!!!

Question 19

What does ‘sick day rules’ mean?

What are some of these?

Answer 19

Rules of what to do or stop if “sick”

• never stop background insulin
• check BM and for ketones frequently
• extra short acting insulin needed if BM or ketones rising
• drink fluid = 100ml/hr
• seek medical help if not handling well

Question 20

What is the diagnostic criteria/definition of hypoglycaemia?

Answer 20

BM <3.5mmol/L (4.0mmol/L if in hospital)

Question 21

Why do hypos occur?

Answer 21

Over treatment with:

• insulin
• sulphonylureas (gliclazide)

Or normal doses without eating properly

E.g. insulin requirement:level mismatch