Endocrine - Level 1 Flashcards
Definition of hypoglycaemia?
- Defined as blood glucose ≤4mmol/L
- In hospital, any blood sugar <4mmol/L should be treated promptly
- Can mimic any neurological presentation
Prevalence of hypoglycaemia?
- 30% prevalence in T1DM
Risk factors of hypoglycaemia?
o Strict glycaemic control o Impaired awareness of hypoglycaemia o Increased duration of diabetes o Alcohol o Injection into lipohypertrophic sites
Causes - diabetic of hypoglycaemia?
Insulin or sulphonylurea with increased activity, missed meal, overdose
Causes - non-diabetic of hypoglycaemia?
Exogenous drugs (insulin, sulphonylureas, alcohol, ACEi, BB)
Pituitary insufficiency
Liver Failure
Addison’s disease
Insulinoma
Non-pancreatic neoplasms (fibrosarcoma)
Symptoms of hypoglycaemia?
- Rapid onset
- Preceded by odd behaviour
- Autonomic
o Sweating, tachycardia, anxiety, hunger, tremor, palpitations - Neuroglycopenic
o Confusion, drowsiness, visual trouble, seizures and coma
Investigations of hypoglycaemia?
- BMG (if <3, take lab glucose)
- Bloods – glucose, LFTs, TFTs, HbA1c
Diagnosis of hypoglycaemia - triad?
- Diagnosis (Whipple’s triad)
o Plasma hypoglycaemia
o Symptoms of low blood sugar
o Resolution with correction of hypoglycaemia
Management of hypoglycaemia - conscious or mild hypoglycaemia?
10-20g of fast-acting oral carbohydrates (Lucozade, sugar lumps, GlucoGel, Dextrogel)
• Repeat BMG after 15 mins, repeat step up to 1-3 times if needed
After treatment, give longer-acting carbohydrate (sandwich, fruit, milk, biscuits or next meal)
Management of hypoglycaemia - unconscious or severe hypoglycaemia?
If IV Access not available rapidly:
Glucagon 1mg, SC/IM (not suitable in alcohol, sulfonylureas or liver failure)
• If not effective in 10 minutes, give IV glucose
If IV access: IV glucose (e.g. 15g of 150ml 10% glucose over 15 minutes or 10g of Glucose 20% (50mls)) through large vein and large-gauge needle • Infusion can be given if prolonged
After treatment, give 20g longer-acting carbohydrate (sandwich, fruit, milk, biscuits or next meal)
Management if prolonged hypoglycaemic coma?
o Usually >5 hours and caused by cerebral oedema
o IV mannitol and dexamethasone
o IV glucose
When are ketones produced by body?
- Ketoacidosis is alternative metabolic pathway, normally used in starvation states
- Produces acetone as by-product
Pathology of DKA?
o Excessive glucose, but due to lack of insulin, cannot be up taken into cells to be metabolised
o Causes osmotic diuresis, with Na and water loss
o Pushes body into starvation states where ketoacidosis is only mechanism of production – increased lipolysis
o Produces non-esterized fatty acids, oxidised in liver to ketones
Risk factors of DKA?
o Infection
o Infarction
o Insufficient insulin
o Intercurrent illness
Symptoms and signs of DKA?
o Dehydration – thirst, polydipsia, polyuria, decreased skin turgor, dry mouth, hypotension, tachycardia
o GI – nausea, vomiting, abdominal pain
o Hyperventilation – (resp compensation for metabolic acidosis) Deep rapid (Kussmaul breathing) and smell of acetone on breath
o Altered conscious state, focal neurological deficits
When to get critical care review in DKA? PHOSSVGK
o Pregnant o Heart Failure o Oliguria or Anuria o Sat <92% on air o Systolic BP <90mmHg after 2L of fluid o Venous bicarbonate <5mmol/L or pH<7.1 o GCS<12 o K<3.5 on admission
Essential investigations when DKA suspected?
o FBC, U&E, glucose
o VBG for bicarbonate, K, pH
o Depending on clinical suspicion – ECG/CXR/MSU/blood cultures/pregnancy test
Diagnosis of DKA?
o Hyperglycaemia (>11mmol/L) o Ketonaemia (>3mmol/L or ++ or above on strip marking scale) o Acidaemia (pH<7.3 or plasma bicarbonate <18)
Initial management of DKA?
o ABCDE approach
Secure airway if GCS low
2 large-bore cannulas
o If BP <90 – 500ml Bolus 0.9% saline (max 2L, then call critical care)
Fluid management of DKA?
If BP>90mmHg or responds to 1st bolus:
1L 0.9% Saline in 1st hour, 1L over 2 hours, 1L over 2 hours, 1L over 4 hours, 1L over 4 hours, 1L over 6 hours
Insulin management of DKA?
Insulin – fixed rate
IVI 50U actrarapid (soluable insulin) to 50mL 0.9% saline – 0.1u/kg/hr (1 unit/ml)
• Can increase to 1u/h
Continue long-acting insulin therapies
Call Diabetes specialist team
Subsequent management of DKA - potassium replacement?
o Potassium Replacement (40mmol/L KCl added)
Don’t add K to 1st bag unless <3.5
Monitor UO hourly, infuse at 20mmol/hour
Check U&E hourly initially and replace as required
• >5.5 None
• 3.5-5.5mmol/L – 40mmol KCl/litre of IV fluid
• <3.5mmol/L – senior review (>40 may be necessary)
Continuous ECG monitoring
Subsequent management of DKA - further management after potassium replacement?
o Catheter and NG tube (if drowsy)
o LMWH Anticoagulation
o When glucose <14mmol/L
10% glucose at 125mL/h to prevent hypoglycaemia alongside sodium chloride
Monitoring in DKA?
o Vital signs hourly for 1st 4-6 hours and frequently thereafter
o Capillary glucose, ketones & VBG hourly
o U&Es every 6 hours
Targets of treatment in DKA?
o Blood glucose fall of >3mmol/L/hour until 14mmol/L (if not falling, increased insulin to 1U/hr)
o Venous bicarbonate rise >3mmol/L/hour until 15mmol/L
o Capillary ketones fall >0.5mmol/L/hour until <0.6mmol/L
Management after recovery in DKA?
o Transfer to SC insulin when patient well, able to eat and drink and venous pH >7.3 or blood ketones <0.6mmol/L
o Give SC fast-acting insulin and a meal and stop infusion
Complications in DKA?
o Cerebral oedema Headache, agitation, fall in heart rate, increased blood pressure o Aspiration pneumonia o Hypokalaemia o Hypomagnesaemia o Hypophosphatemia o VTE
Definition of impaired glucose tolerance?
FPG <7 and 75g OGTT 2h 7.8-11.0
Definition of impaired fasting glucose?
FPG 6.0-7.0
