diabetic emergencies (see DM for DKA)

Question 1

what are 3 acute complications of diabetes

Answer 1

1. DKA (usually in type 1);
2. Hyperosmolar Hyperglycaemic state (HHS);
3. hypoglycaemia

Question 2

risk factors for Hyperosmolar Hyperglycaemic state (4)

Answer 2

1. UTI
2. non compliance w meds
3. elderly
4. lives alone

Question 3

what is Hyperosmolar Hyperglycaemic state (4)

Answer 3

there is no formal definition but these 4 criteria are widely adopted:
1. Hypovolaemia
2. Hyperglycaemia (> 30 mmol/L)
3. Mild or absent ketonaemia (blood ketones < 3 mmol/L)
4. High osmolality

Question 4

Hyperosmolar Hyperglycaemic state pathophys (5 - write out!)

Answer 4

1. relative lack of insulin (not absolute => no ketosis) is coupled with a rise in counter-regulatory hormones -> rise in glucose
2. excessive glucose leads to massive osmotic diuresis within the kidneys with the loss of essential electrolytes such as sodium and potassium
3. As water is lost, there is profound dehydration and reduced circulating volume, resulting in hyperosmolarity and marked hyperglycaemia
4. The increase in osmolality increases compensatory mechanisms e.g. release of ADH and stimulation of thirst -> if this cannot compensate for the renal water loss (e.g. elderly patients with co-morbidities) then hypovolaemia develops with progression to acute kidney injury, electrolyte disturbances, hypotension and coma
5. hyperosmolar state of the condition leads to hyperviscosity that increases the risk of arterial and venous thrombosis

Question 5

6 precipitating factors of hyperosmolar hyperglycaemic state

Answer 5

1. Infection
2. High-dose steroids
3. Myocardial infarction
4. Vomiting
5. Stroke
6. Poor treatment concordance

Question 6

9 symptoms of hyperosomolar hyperglycaemia state

Answer 6

1. Polydipsia
2. Polyuria
3. Nausea
4. Vomiting
5. Muscle cramps
6. Weakness
7. Altered mental status
8. Seizures
9. Coma

Question 7

glucose + osmolarity findings in hyperosmolar hyperglycaemia

Answer 7

Laboratory glucose: > 30 mmol/L
Serum osmolality: > 320 mOsm/kg

Question 8

hyperosmolar hyperglycaemia mgx

Answer 8

1. Urgently start intravenous fluids as soon as you suspect hyperosmolar hyperglycaemic state (1 L of 0.9% sodium chloride over 1 hour );
2. Start a fixed-rate intravenous insulin infusion immediately ONLY if there is significant ketonaemia - only after giving IV fluids!;
3. correct serum osmolality, electrolytes, and blood glucose;
4. identify and treat underlying cause

Question 9

HHS vs DKA

Answer 9

HHS - relative decreased insulin
DKA - absolute decreased insulin (may result from build up of HHS over several weeks)

Question 10

how long can DKA be compensated for

Answer 10

can only compensate for 72hrs due to massive dehydration

Question 11

what other conditions will increase the risk of fluid over load in DKA pts (3)

Answer 11

heart failure; renal failure; liver failure