Hpyerglycemia Flashcards
DKA
Diabetic keto-acidosis
What is DKA
It occurs when the body produces high levels of blood ketones in response to its inability to produce or use insulin
HHS
Hyperosmolar hyperglycaemic state
HONK
hyperosmolar non- ketotic state
what is HONK
A very high blood glucose level causes severe dehydration and elevated blood osmolality without significant ketoacidosis
to convert from mg/dL to mmol/L
divide by 18
calculate correct Na
Add 1.6 to Na level for each 6mmol/L glucose above 6
Pathophysiology of DKA
-is caused by absolute or relative decrease in insulin levels.
-Plasma glucose increase causes an osmotic diuresis, with Na + and water loss (up to 8–10L), hypotension, hypoperfusion, and shock.
-Normal compensatory hormonal mechanisms are overwhelmed and lead to an increase in lipolysis.
-In the absence of insulin this results in the production of non-esterified fatty acids, which are oxidized in the liver to ketones.
-Younger undiagnosed diabetics often present with DKA developing over 1–3 days. Plasma glucose levels may not be grossly increased; euglycaemic ketoacidosis can occur.
pathophysiology of HONK
-It is caused by intercurrent illness, inadequate diabetic therapy and dehydration.
-It develops over days/weeks, and is more common in the elderly.
-HHS is characterized by an increase in glucose levels (> 30mmol/L), increased blood osmolality, and a lack of urinary ketones.
-Mortality is 85–10 %, but may be even higher in the elderly.
in which type diabetes does HONK occur
type 2
symptoms of DKA
dehydration
thirst
polydipsia
polyuria
decreased skin turgor
dry mouth
hypotension
tachycardia
GI symptoms of DKA
nausea
vomitting
abdominal pain
Hyperventilation in DKA
(respiratory compensation for the metabolic acidosis) with deep rapid breathing (Kussmaul respiration) and the smell of acetone on the breath
altered mental status in DKA
True coma is uncommon, but altered conscious states and/or focal neurological deficits (which may correct with treatment) are seen particularly in older patients with HHS or patients with severe DKA.
common underlying conditions of DKA: the four Is
Infection: common primary foci are urinary tract, respiratory tract, skin. (sepsis, pancreatitis)
Infarction: myocardial, stroke, GI tract, peripheral vasculature.
(ACS)
Insufficient insulin.
Intercurrent illness: many underlying conditions precipitate or aggravate DKA and HHS, as mentioned above. (CVA)
Differential diagnosis of DKA
Acute Pancreatitis
Alcoholic Ketoacidosis
Appendicitis
Cystitis in Females
Hyperosmolar Coma
Hypophosphatemia
Hypothermia
Lactic Acidosis
Metabolic Acidosis
Salicylate Toxicity
Septic Shock
immediate management
-Stabilise patient using the ABCs approach
If altered consciousness/coma is present, provide and maintain a patent airway.
-Assess breathing and circulation. High flow O2 if hypoxic.
-Assess blood pressure and circulation. Establish IV access. Immediate fluid bolus if circulation impaired (use crystalloid);
-Assess level of consciousness, check glucose stat and 2 hourly.
-Expose patient enough to be able to do a thorough assessment, but minimize heat loss.
Fluid management
Fluid boluses of 0.9% Saline (20-30ml/kg) till systolic blood pressure above 90.
If glucose drops below 15mmol/L change to 1L 5% Dextrose containing fluid (Rehydration Solution) 6 Hourly
fluid management in HHS
Consider changing to 0.45% Saline if glucose and osmolality not declining despite usual regime above.
drug treatment
insulin
electrolyte replacement
when to start insulin
Patients is resuscitated to a systolic blood pressure of at least 90.
Potassium level is known and relative or absolute potassium deficit is being addressed with potassium replacement
administration of insulin
Start an infusion of soluble insulin using an IV pump or paediatric burette at 6U/hr (50 units Actrapid in 200ml 0.9% Saline, run at 24ml/hour). No loading dose is required.
If no rate minder is available
10 units Actrapid subcutaneously stat, then 6 units subcutaneously hourly
Check plasma glucose levels every hour initially.
Keep infusion rate constant, but change to 5% Glucose containing solution once glucose level falls below 15mmol/L.
electrolyte replacement
Although total body K + is low, plasma K + may be normal, increased or decreased.
With treatment, K + enters cells and plasma levels decrease: therefore, unless initial K + levels are > 5mmol/L, give K+
other electrolytes
Other electrolytes such as Ca2+, Mg2+, and PO42– are commonly disturbed, but rarely need emergency correction.
Bicarbonate administration has not been shown to improve mortality or morbidity. Has been shown to worsen the ketosis and delays ketone clearance. Only consider if patient has been fully resuscitated to a systolic blood pressure above 90mmHg and the pH is below 7. Consider an NG tube to decrease risk of gastric dilation and aspiration.
adjunctive treatment
antibiotics
supportive management
antibiotics
Not for routine administration.
If infective focus found administer per suspected organism.
Consider empiric broad spectrum antibiotics if pH remains below 7 or the patient is not responding to treatment.
supportive management
Monitor urine output (most accurate with urinary catheter).
If patient is drowsy/decreased level of consciousness give DVT prophylaxis.
Arrange admission to ICU, HDU, or acute medical admissions unit.
normal glucose
<11 mmol/L
normal bicarbonate
> /= to 18
normal ph
> 7.3
normal anion gap
<12
investigations
Check blood glucose and ketone levels and test the urine for glucose and ketones.
Send blood for U&E, blood glucose, creatinine, osmolality (or calculate it):
mOsm/L= (2 × Na + ) + glucose (mmol/L) + urea (mmol/L).
Check Venous Blood Gas (look for metabolic acidosis ± respiratory compensation).
FBC
CXR (to search for pneumonia).
ECG and cardiac monitoring (look for evidence of hyper/hypokalaemia).
If infection/sepsis suspected, as appropriate:
-Blood cultures
-Throat or wound swabs
-Urine/sputum microscopy and culture.
