L17 - Acute complications diabetes Flashcards
Diabetic ketoacidosis - patho
osmotic diuresis - dehydration
unchecked gluconeogenesis - hyperglycemia
unchecked ketogenesis - ketosis
Dissociation of ketone bodies into hydrogen ion and anions - Anion-gap metabolic acidosis
How is acidosis managed?
intracellular buffering H+/K+ exchange
respiratory compensation - hyperventilation
renal excretion of H+ ions
What are precipitating factors in diabetic keto?
infections - pneumonia/viral
error/missed insulin administration
myocardial infarction
drugs - steroid
diabetic ketoacidosis signs and symptoms
thirst polyuria - sign dry mouth, sunken eyes, postural hypotension
Nausea vomiting - facial flush, hyperventilation
clinical features of diabetic ketoacidosis
age - mostly young in t1d
precipitating causes - insulin deficiency
serum sodium - normal or low
blood glucose - usually less than 40 mmol/l
serum bicarbonate less than 14mmol/l and pH less than 7.3
serum ketones +++++
mortality 5% depending ona age
subsequent course: insulin dependent
5 step plan for managing diabetic ketoacidosis?
1 - confirm diagnosis and check for precipitating causes
2 - rehydrate and monitor fluid balance. iv fluids saline with added potassium consider a urinary catheter
3 - lower glucose - iv insulin
4 - monitor electrolytes - potassium and sodium
5 - prevent clots - prophylactic low molecular weight heparin
Other management factors for DKA?
is the patient conscious? assess GCS
At risk of aspiration - consider NG tube
monitor recovery - glucose, ketones, pH, potassium - hourly
DKA recovery
pH normal ketones less than 2+(urine) vomiting settled resume normal diet switch from IV to normal subcutaneous insulin
what is Hyperosmolar Hyperglycaemic State (HHS)
Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.
Patient has got insulin, so there is no fat breakdown but not enough insulin to stop glucose getting higher and higher so pee the glucose out leading to dehydration
commonly in old and frail patients who dont drink enough water
HSS age
usually 40+
preciptating causes for HSS
previously undiagnosed, steroids, diuretics, sugar
serum sodium HSS
Usually high
blood glucose HSS
Often more than 40 mmol/l
serum bicarbonate and pH in HSS
Bicarbonate - normal
pH - 7.4
serum ketones in HSS
0
Subsequent course HSS
Diet/tablet controlled
HSS management
correct the profound dehydration
What is hypoglycemia?
Hypoglycaemia is a biochemical term and exists when blood sugar < 4mmol/l but is often used to describe a clinical state. The clinical syndrome associated with hypoglycaemia develops as the nervous system becomes glucose deficient or ‘neuroglycopaenic
Symptoms of hypoglycaemia
Autonomic – sympathomedullary activation Sweating, feeling hot Trembling or shakiness Anxiety palpitations Neuroglycopenic Dizziness, light-headedness Tiredness Hunger, nausea Headache Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism Coma and convulsions, hemiplegia
Hypoglycemia causes
insulin - inappropriately excessive doses
not eating/insufficient carbohydrate
sulfonylureas
how can you counter regulate hypoglycemia?
Glucagon, adrenaline, cortisol and GH all have ‘anti-insulin effects’
Glucagon stimulates glycogenolysis and gluconeogenesis and is probably primary response
Adrenaline increases glycogenolysis
GH and cortisol limit glucose disposal in peripheral tissues, but this effect takes several hours so of little benefit acutely
Sympathetic nerves may also directly activate hepatic glycogenolysis and stimulate glucagon secretion
Hypoglycemia treatment
Minor episodes: 20g carbohydrate as sugary drink, fruit juice, glucose tablet
glucose gel
Hypoglycemic coma -
IM or IV glucagon 1mg
IV dextrose 25g
mild/moderate hypo treatment
patient conscious and able to swallow
give 5 level teaspoons glucose powder in water
or 120mls lucozade or 5 glucose tablets
test blood glucose after 15 minutes
if less than 4 mmol/l repeat up to 3 times
if more than 3 times, consider 1mg glucagon IM
then long acting carbohydrate - 2 biscuits or a slice of bread
severe hypo treatment
patient unconscious or nil by mouth or very aggressive
check ABC stop any IV insulin
if pt suitable for IM glucagon give 1mg.
if not give 10% IV glucose 150 ml repeat up to 3 times
recheck glucose levels after 15 mins. long acting carb
If NBM give 10% glucose infusion at 100ml/hr until no longer NBM
