Diabetic Emergencies Flashcards
define diabetic ketoacidosis (DKA)
disordered metabolic state due to absolute or relative insulin deficiency accompanied by an increase in counter-regulatory hormones e.g. glucagon, adrenaline, cortisol and GH
can DKA occur in both type 1 and type 2 diabetes?
yes
pathophysiology of DKA
- absolute deficiency of insulin causes stress hormone activation
- lipolysis, proteolysis, glycogenolysis and decreased glucose utilisation results
- leads to hyperglycaemia and dehydration with ketogenesis and acidosis
diagnosis of DKA
- ketones >3mmol/L or significant ketonuria
- blood glucose >11.0mmol/L (most are 40mmol/L, if 11-100 it is euglycaemic KA)
- bicarbonate <15mmol/L or venous pH <7.3 (acidosis)
- potassium raised above 5.5mmol/L
- creatinine and lactate raised
- sodium often low
how can DKA cause death
hypokalaemia
aspiration pneumonia
ARDS
cerebral oedema (children)
precipitating factors of DKA
new diagnosis infection illicit drugs alcohol poor adherence to insulin
presentation of DKA
- osmotic symptoms e.g. thirst, polyuria and dehydration
- ketones= flushing, vomiting, abdominal pain, Kussmaul’s respiration
- ketones on breath (sweet smelling/pear drop breath)
- associated conditions e.g. underlying sepsis and gastroenteritis
define Kussmaul’s respiration
this is deep laboured breathing due to metabolic acidosis and aiming to compensate by blowing off excess CO2
complications of DKA
hypokalaemia
ARDS
cerebral oedema
gastric stasis
management of DKA
replace losses= fluids, insulin K+
address risks= NG tube, monitor K+, LMWH and sepsis
what does ketone monitoring measure?
beta-hydroxybutyrate
ketone monitoring normal result
<0.6mmol/L
what does urine ketones measure?
acetoacetate which indicates levels 2-4 hours previously
when can a DKA patient be taken off IV insulin and moved to SC?
blood ketones have reduced
bicarbonate is normal
patient is eating and drinking
when should IV insulin be stopped after SC injection?
30 minutes after SC dose
define hyperglycaemia hyperosmolar syndrome (HHS)
relative deficiency of insulin with more dehydration than DKA (can be mixed HHS/DKA picture)
presentation of HHS
- often older patients or young afro-Caribbean
- high refined CHO intake pre-presentation
- risk associations include CVS disease, sepsis and medication (steroid/thiazides)
- different to DKA in terms of more likely in type 2, older patients, high glucose intake, infection or steroids
diagnosis of HHS
- hypovolaemia
- glucose >50mmol/L (higher than DKA)
- ketones <3mmol/L (less than DKA)
- bicarbonate >15 or pH above 7.3
- osmolality >320 (normal is 275-295)
management of HHS
- diet/ OHA/ insulin
- fluids and insulin more slowly as risk of fluid overload
- LMWH for ALL
presentation of alcohol induced ketoacidosis
dehydration
diagnosis of alcohol induced ketoacidosis
ketonemia >3mmol/L
bicarbonate <15mmol/L
pH below 7.3
glucose may be normal
management of alcohol induced ketoacidosis
high dose vitamins (pabrinex)
fluids
anti-emetics
insulin
what is lactate?
this is the end product of anaerobic metabolism
what does clearance of lactate require?
hepatic uptake
aerobic conversion to pyruvate then glucose
normal lactate range
0.6-1.2mmol/L (use ion gap to diagnose)
two types of lactate acidosis
type A is associated with tissue hypoxaemia
type B is associated with liver disease and diabetes
presentation of lactic acidosis
hyperventilation
confusion
coma
