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Year 2 - T2 Theme 1 > L17 - Acute complications of diabetes > Flashcards

L17 - Acute complications of diabetes Flashcards

1
Q

Insulin levels in diabetic keto-acidosis

A
  • Absolute insulin deficiency
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2
Q

Insulin levels in hyperosmolar hyperglycaemia state

A
  • Relative insulin deficiency
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3
Q

What is hyperosmolar hyperglycaemia state

A

Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis

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4
Q

Symptoms of hyperosmolar hyperglycaemia state

A

Symptoms include signs of dehydration, weakness, legs cramps, vision problems, and an altered level of consciousness.

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5
Q

Insulin levels in hypoglycaemia

A
  • Relative insulin excess
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6
Q

Effects of insulin deficiency

A
  • Glycogenolysis
  • Glucagon, adrenaline(cortisol) release
  • Lipolysis and reduced esterification of fatty acids
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7
Q

How does lipolysis and reduced esterification of fatty acids increase hepatic glucose output and cause hyperglycaemia

A

–> NEFA –> Ketones –> acetone, acetoacetate, hydroxybutyrate

–> glycerol –> gluconeogenesis –> increase in hepatic glucose output and hyperglycaemia

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8
Q

How does proteolysis and reduced uptake of amino acids increase hepatic glucose output and cause hyperglycaemia

A

Proteolysis and reduced uptake of amino acids –> alanine –> gluconeogenesis –> increase in hepatic glucose output and hyperglycaemia

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9
Q

What causes hyperglycaemia in diabetic ketoacidosis

A
  • Unchecked gluconeogenesis
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10
Q

What causes osmotic diuresis in diabetic ketoacidosis

A
  • Dehydration
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11
Q

What causes ketpsis in diabetic ketoacidosis

A
  • Unchecked ketogenesis
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12
Q

What cases anion-gap metabolic acidosis in diabetic ketoacidosis

A
  • Dissociation of ketone bodies into hydrogen ion and anions
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13
Q

How can insulin deficiency lead to CV collapse

A

Insulin deficiency –> hyperglycaemia –> glycosuria –> dehydration –> renal failure –> shock –> CV collapse

Insulin deficiency –> lipolysis –> increase in FFAs –> ketones –> acidosis –> CV collapse

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14
Q

Physiological effects of insulin deficiency in adipose tissue

A

• Increased lipolysis and reduced esterification of fat
• Insulin deficiency
• Glucagon/adrenaline excess
Results in excess FFA and glycerol from breakdown triglycerides
• FFA substrate for hepatic synthesis of ketone bodies
• Acetoacetate/Hydroxybutyrate – strong organic acids
• (Acetone)
• Rate of ketogenesis is linked to rate of gluconeogenesis
• Muscle and brain can utilise ketones as main energy substrate

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15
Q

What causes ketoacidosis

A
  • Ketoacidosis results when ketone body production exceeds rate of utilisation in peripheral tissues (brain and muscle) and renal clearance
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16
Q

How does insulin deficiency give rise to nausea and abdo pain

A

Lipolysis and reduced esterification of fatty acids –> NEFA –> Ketones –> acidosis –> nausea, abdo pain

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17
Q

How does insulin deficiency cause dehydration

A

Increased hepatic glucose output and hyperglycaemia –> osmotic diuresis –> dehydration

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18
Q

How is acidosis in diabetic ketoacidosis managed

A

• Intracellular buffering - H+ / K+ exchange
○ Potassium hydrogen ion pump
• Respiratory compensation – hyperventilation
○ H+ stimulates respiratory centres
○ Breathe off CO2 (H+ + HCO3- H2O + CO2)
• Renal excretion of H+ (slow response)

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19
Q

Electrolyte disturbances in diabetic ketoacidosis

A
  • Potassium depletion - maybe > 250 mmol
  • Sodium depletion
  • Dehydration
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20
Q

Main differences between cation concentrations between ECF and ICF

A
  • Higher Na+ concentration in interstitial fluid

- Higher K+ concentration in ICF(muscle) - this is due to intracellular buffering - H+/K+ exchange

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21
Q

Age most affected by diabetic ketoacidosis

A
  • Mostly young T1DM
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22
Q

Precipitating causes of diabetic ketoacidosis

A
  • Relative or absolute insulin deficiency
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23
Q

Serum sodium levels in DKA

A

Normal or low

24
Q

Blood glucose levels in DKA

A

Usually <40mmol/l

25
Serum bicarbonate/pH - DKA
< 14 mmol/l / ph<7.3
26
Diabetic ketoacidosis - specific precipitating factors
- Infections - pneumonia, urinary tract, viral illnesses, gastroenteritis - Error/missed insulin administration - Myocardial infarction - Previously undiagnosed type 1 diabetes - Drugs - steroids
27
Symptoms of diabetic ketoacidosis attributed to hyperglycaemia + dehydration
- Thirst and polyuria - Weakness and malaise - Drowsiness - Confusion
28
Symptoms of diabetic ketoacidosis attributed to acidosis
- Nausea and vomiting - Abdominal pain - Breathlessness
29
Signs of diabetic ketoacidosis attributed to hyperglycaemia + dehydration
- Dry mouth - Sunken eyes - Postural or supine hypotension - Hypothermia and coma
30
Signs of diabetic ketoacidosis attributed to acidosis
- Facial flush - Hyperventilation - Smell of ketones on breath and ketonuria
31
Diabetic ketoacidosis - management
- Confirm diagnosis and check for precipitating causes - Rehydrate and monitor fluid balance (IV fluids - saline with added potassium, consider urinary catheter) - Lower glucose (intravenous insulin - fixed rate 0.1 unit/kg/hr - Monitor electrolytes - potassium(and sodium) - Prevent clots - prophylactic low molecular weight heparin
32
DKA - other management factors
- Is the patient conscious? Assess GCS If concern, call ITU - At risk of aspiration Consider NG tube - Monitor recovery Glucose, ketones, pH, potassium - hourly
33
DKA - recovery
- pH normal, ketones <2+ (urine), vomiting settled - Resume normal diet - Switch from intravenous to normal subcutaneous insulin
34
Hyperosmolar hyperglycaemic state - normal age
Usually > 40 years
35
Precipitating causes of hyperosmolar hyperglycaemic state
- Previously undiagnosed - Steroids - Diuretics - Sugar
36
HHS - Serum sodium levels
- Usually high
37
HHS - blood glucose levels
- Often > 40mmol/l
38
HHS - Serum bicarbonate/pH
- Normal / pH 7.4
39
HHS - Serum ketones
0
40
HHS - mortality
30% (thromboses)
41
HHS subsequent course
Diet/tablet controlled
42
DKA - mortality
5% depending on age
43
DKA - subsequent course
Insulin dependent
44
HHS - management
• Correct the profound dehydration * Confirm diagnosis and check for precipitating causes * Rehydrate & monitor fluid balance * Iv fluids - saline with added potassium * Consider urinary catheter * Lower glucose (once glucose not improving with fluids) * Intravenous insulin – fixed rate 0.05Unit/kg/hr * Monitor electrolytes * Potassium (and sodium) * Prevent clots * Treatment low molecular weight heparin
45
What is hypoglycaemia
- Hypoglycaemia is a biochemical term and exists when blood sugar <4mmol/l but is often used to describe a clinical state
46
Classification of hypoglycaemia
- Asymptomatic - awake vs sleeping - Mild symptomatic (patient can treat himself) - Severe symptomatic (help needed by third party) - Coma and convulsions
47
Symptoms of hypoglycaemia - autonomic - sympathomedullary activation
- Sweating, feeling hot - Trembling or shakiness - Anxiety - Palpitations
48
Neuroglycopenic symptoms of hypoglycaemia
- Dizziness, light-headedness - Tiredness - Hunger, nausea - Headache - Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism - Coma and convulsions, hemiplegia
49
Causes of hypoglycaemia
- Insulin Inappropriately excessive doses Not eating, or insufficient carbs - Sulfonylureas
50
Hypoglycaemia - counter-regulation
- 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
51
Treatment of minor episodes of hypoglycaemia
- 2-g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something 'starchy' to eat - Glucose gels
52
Treatment of hypoglycaemic coma
- IM or IV glucagon 1mg | - IV dextrose 25g (150ml 10% glucose)
53
How many times can glucagon be given per day
- Glucagon can only be given once daily | - It will not reverse hypoglycaemia in patients with recurrent hypos, anorexia or severe liver disease
54
Treatment pathway - Mild/moderate hypoglycaemia
Patient conscious, orientated and able to swallow --> give 5 level teaspoons glucose powder in water or 120 mls lucozade or 5 glucose tablets - Test blood glucose after 15 mins, if <4 mmol/l repeat up to 3 times - If this has been repeated 3 times, consider 10% glucose IV 100ml/hr or 1 mg glucagon IM Give long acting carbs (eg 2 biscuits or a slice of bread or next meal if due) - DO NOT omit subsequent doses of insulin
55
Treatment pathway - Severe hypoglycaemia
- Patient unconscious/fitting/very aggressive or nil by mouth (NBM) --> Check ABC, stop any IV insulin. If patient suitable for IM glucagon give 1 mg. If not give 10% IV glucose 150ml. Repeat up to 3 times --> Recheck glucose level after 15 mins it should now be above 4mmol/L Give long acting carbs

Year 2 - T2 Theme 1 (20 decks)

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