High Glucose States Flashcards

1
Q

Diabetic Ketoacidosis

A

Diabetic Ketoacidosis (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

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2
Q

Why do people die from diabetic ketoacidosis?

A
Adults:
Hypokalaemia, Aspiration Pneumonia, ARDS, 
Co-morbidities
Children:	
Cerebral oedema
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3
Q

Common precipitants of DKA

A

infections (20 to 25%) – may be an over-estimate
Illicit drugs and alcohol (10 to 15%)
non-compliance with treatment (45 to 50%) – may be under-estimate
newly diagnosed diabetes (25% and falling?)

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4
Q

Diabetic Ketoacidosis Diagnosis

A

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

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5
Q

Classical biochemistry DKA

A
Glucose
-Median level around 40 mmol/L
-From 10 [‘euglycaemic ketosis’] to 100 mmol/L 
Potassium
-Usually raised above 5.5 mmol/L
-Beware the low normal
Creatinine: often raised
Sodium: often reduced
Raised lactate is very common
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6
Q

Management of DKA

A
Replace losses
Fluid
Initially with 0.9% sodium chloride
Glucose falls to about 15, switch to dextrose
Insulin
Potassium
Phosphate [rarely] and Bicarbonate [almost never] replaced
Address risks
? is a naso-gastric tube required?
Monitor K+
Prescribe prophylactic LMWH
Source sepsis: CXR, Blood Culture, MSSU +/- viral titres, etc
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7
Q

Urine ketone testing

A

Measures acetoacetate
Indicates levels of ketones 2-4 hours previously
Ketonuria persists after clinical improvement due to mobilisation of ketones from fat tissue

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8
Q

Blood ketone testing

A

Optium meter
Measures beta-hydroxybutyrate
Meter range 0 - 8mmol/L
< 0.6 mmol/L normal

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9
Q

When should you admit someone to hospital for DKA

A
Unable to tolerate oral fluids
Persistent vomiting
Persistent hyperglycaemia
Persistent positive/increasing levels of ketones
Abdominal pain / breathlessness
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10
Q

Clearance of lactate?

A

Clearance requires hepatic uptake and aerobic conversion to pyruvate then glucose

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11
Q

Where does lactate come from?

A

Lactate comes from red cells, skeletal muscle, brain and renal medulla

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12
Q

Type A lactic acidosis

A
Associated with tissue hypoxaemia
Infarcted tissue, eg ischaemic bowel
Cardiogenic shock
Hypovolaemic shock
Sepsis [endotoxic shock]
Haemorrhage
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13
Q

Type B lactic acidosis

A

May occur in Liver disease
Associated with drug therapy, eg Metformin
Associated with Diabetes
10% of cases of DKA associated with lactate >5 mmol/L.
With Metformin usually in severe illness states or renal failure
Also consider rare inherited metabolic conditions if well and non-diabetic

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14
Q

Which type of lactic acidosis is associated with diabetes?

A

Type B lactic acidosis

also associated with metformin

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15
Q

Normal range of lactate

A

0.6 - 1.2. is normal range for lactate

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16
Q

Lactic acidosis presentation

A

Hyperventilation
Mental confusion
Stupor or coma if severe

17
Q

HHS risk associations?

A

Cardiovascular event [stroke or MI]
Sepsis
Medications: Glucocorticoids and thiazides

18
Q

HHS diagnosis?

A

Hyperglycemia
Hypovolemia
Osmolality

19
Q

Treatment for HHS? (vs DKA)

A

Fluids:
More slowly due to increased risk of cerebral oedema
Insulin:
More slowly as more sensitive (e.g. 3units/hour)
Sodium:
Avoid rapid fluctuations – e.g. ≤0.5mmol/l/hr
May need to consider 0.45% Saline*
Co-morbidities more likely
Screen for vascular event (eg. silent MI), sepsis
LMWH for all unless contra-indicated