List I - Act Core Conditions Flashcards
What is the definition of hypoglycaemia?
- Blood glucose <4.0 mmol/L
How common is hypoglycaemia in people with type 1 diabetes mellitus?
- People with type 1 diabetes mellitus experience around two episodes of mild hypoglycaemia per week
Which scale is used to classify hypoglycaemia?
- The Edinburgh Hypoglycaemia Scale
What are the autonomic features of hypoglycaemia?
- Sweating
- Palpitations
- Shaking
- Hunger
General malaise
- Headache
- Nausea
What are the neuroglycopenic features of hypoglycaemia?
- Confusion
- Drowsiness
- Odd behaviour
- Speech difficulty
- Incoordination
What are the medical risk factors for hypoglycaemia?
- Tight glycaemic control
- Previous history of severe hypo
- Undetected nocturnal hypo
- Long duration of diabetes
- Poor injection technique
- Impaired awareness of hypoglycaemia
- Preceding hypoglycaemia (less than 3.5 mmol/L
- Severe hepatic dysfunction
- Renal dialysis therapy
- Impaired renal function
- Inadequate treatment of previous hypoglycaemia
- Terminal illness
What are the lifestyle risks of hypoglycaemia?
- Increased exercise (relative to usual)
- Irregular lifestyle
- Increasing age
- Alcohol
- Early pregnancy
- Breast feeding
- Injecting into areas of lipohypertrophy
- Inadequate blood glucose monitoring
Reduced carbohydrate intake:
* Food malabsorption e.g. gastroenteritis, coeliac disease
What are the potential medical causes of inpatient hypoglycaemia?
- Inappropriate use of ‘stat’ or ‘PRN’ quick acting
insulin
• Acute discontinuation of long term steroid therapy
• Recovery from acute illness/stress
• Mobilisation after illness
• Major amputation of a limb
• Inappropriately timed diabetes medication for
meal/enteral feed
• Incorrect insulin prescribed and administered
• IV insulin infusion with or without glucose infusion
• Inadequate mixing of intermediate acting or mixed
insulins
• Regular insulin doses being given in hospital when
these are not routinely taken at home
What are the potential reduced carbohydrate causes of inpatient hypoglycaemia?
* Missed or delayed meals • Less carbohydrate than normal • Change of the timing of the biggest meal of the day i.e. main meal at midday rather than evening • Lack of access to usual between meal or before bed snacks • Prolonged starvation time e.g. ‘Nil by Mouth’ • Vomiting • Reduced appetite • Reduced carbohydrate intake
What is the management for hypoglycaemia in adults who are conscious, orientated and able to swallow?
1) 10-20g quick acting carbohydrate e.g.
- 150-200 ml pure fruit juice
- 50-100 ml original Lucozade
- 2-4 heaped teaspoons of sugar dissolved in water
2) Repeat capillary blood glucose 10-15 minutes later, if still less than 4.0 mmol/L repeat step 1 up to 3 times
3) If blood glucose remains <4.0 mmol/L after 45 minutes or 3 cycles contact a doctor - consider 1 mg glucagon IM or IV 10% glucose infusion at 100ml/hr
4) When symptoms improve or normoglycaemia is restored - carbohydrate intake of the next meal should be increased (e.g. bread, potatoes or pasta)
or long acting starchy carbohydrate such as a sandwich or some biscuits to maintain blood glucose
What is the management for hypoglycaemia in adults who are unconscious and unable to swallow? (severe hypoglycaemia)
- IM glucagon should be administered immediately
- Children <8 years or body weight less than 25 kg 500 mcg of glucagon should be given
- All others 1 mg of glucagon should be given
Emergency transfer to hospital should be arranged if:
- IM glucagon not availble
- Family members are not trained to give the glucagon
- Alcohol is the cause of the hypoglycaemia
- If the person does not respond to glucagon treatment within 10 minutes, emergency transfer to hospital should be arranged for treatment with IV glucose
- If the person responds to treatment with glucagon within 10 minutes and if sufficiently awake and able to swallow safely they should eat some oral carbohydrate
- Vomiting is common in the recovery phase and recurrent hypoglycaemia may recur therefore the person should be monitored closely with regular checking of blood glucose
- If hypoglycaemia recurs hospital treatment may be required with IV glucose
How is mild hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?
- Mild - Patient conscious, orientated, able to swallow and able to self-help
- Give 15-20g of quick acting carbohydrate e.g. 1 bottle of glucose liquid or 4-5 glucose tablets
- Test CBG after 15 minutes, if still less than 4 mmol/L, can repeat above 3 times
- If repeated 3 times and still no improvement, consider IV 10% glucose at 100ml/hr or 1mg IM glucagon
How is moderate hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?
- Test CBG after 15 minutes, if still less than 4 mmol/L, can repeat above 3 times, continue to test every 15 minutes
- If repeated 3 times and still no improvement, consider IV 10% glucose at 100ml/hr
How is severe hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?
- Severe - Patient unconscious/fitting/aggressive or nil by mouth (NBM)
- A to E assessment and call for senior help
- If IV access secured give 150ml of 10% glucose over 15 mins (rate 600ml/hr)
- If unable to quickly secure IV access give 1 mg IM glucagon
- Test CBG every 15 minutes till CBG >4mmol/L
- If CBG <4mmol/L and patient still unwell, 150 ml or IV 10% glucose over 15 minutes can be repeated up to 3 times, dependent on clinical response
If all cases of hypoglycaemia, once blood glucose level is above 4mmol/L what is the next step in management according to the Leeds algorithm?
- If able to swallow give 20g of long acting carbohydrate e.g. 2 biscuits/ 1 piece of toast
- If IM glucagon has been used give 40g carbohydrate to replenish glycogen stores
What is important to be aware of regarding IM glucagon?
- Should only be used once during treatment of a hypoglycaemic episode
- Effect will wear off after 30 minutes
If patients are already on a variable rate of IV infusion and experience hypoglycaemia, how should they be managed?
- Reduce insulin infusion to 0.1 unit/hour
- Treat hypoglycaemia
- When blood glucose returns to >4mmol/L restore IV insulin to appropriate rate
What is DKA?
- Metabolic state characterised by the triad of:
- Hyperglycaemia
- Acidosis
- Ketonaemia
When should DKA be suspected?
* Known diabetes or significant hyperglycaemia (blood glucose >11 mmol/L and clinical features of DKA: Symptoms - Increased thirst and urinary frequency - Weight loss - Inability to tolerate fluids - Persistent vomiting and/or diarrhoea - Abdominal pain - Lethargy and/or confusion
Signs
- Fruity smell of acetone on the breath
- Acidotic breathing - deep sighing (Kussmaul) respiration
- Dehydration
- Mild - only just clinically detectable
- Moderate - dry skin and MM, reduced skin turgor
- Severe - sunken eyes and prolonged capillary refill time
- Shock - severely ill with:
- Tachycardia, poor peripheral perfusion and hypotension (late sign)
- Lethargy, drowsiness or decreased level of consciousness (indicating decreased cerebral perfusion)
- Reduced urine output (indicating decreased renal perfusion)
- Ketones in the urine or blood
- High if above 2+ in the urine or above 3 mmol/L in the blood
NB Consider DKA in all people with type 1 diabetes who are unwell bearing in mind that hyperglycaemia may not always be present, low blood ketone levels (less than 3 mmol/L) do not always exclude DKA
What are the precipitating factors for DKA?
- Infection
- Physiological stress (MI, trauma or surgery)
- Inadequate insulin or poor adherence
- Medical conditions such as hypothyroidism or pancreatitis
- Drugs such as corticosteroids, diuretics and sympathomimetic drugs e.g. salbutamol
What is the diagnostic criteria for DKA?
- Glucose >11 mmol/L or known diabetes mellitus
- pH < 7.3 and/or
bicarbonate < 15 mmol/L - Ketones > 3 mmol/L or urine ketones ++ or more on dipstick
All 3 must be present
What is the hospital management of DKA?
1) Fluid replacement: most patients with DKA are deplete of around 5-8 litres
- 0.9% sodium chloride is used initially
2) Insulin: an IV infusion should be started at 0.1 unit/kg/hour (Actrapid). Once blood glucose is < 15 mmol/L an infusion of 5% dextrose should be started
3) Correction of hypokalaemia - insulin will drive potassium into cells and this can result in hypokalaemia therefore potassium needs to be added
4) Long acting insulin regime should be continue, short-acting insulin should be stopped
What is the suggested IV fluid regime for DKA following initial treatment?
- 1L sodium chloride 0.9% over 1 hour, then
- 1L sodium chloride 0.9%* over 2 hours, then
- 1L sodium chloride 0.9%* over 2 hours, then
- 1L sodium chloride 0.9% * over 4 hours.
What is the suggested management of KCl alongside fluid management for DKA?
Plasma K addition: * 40mmol KCl per litre may be necessary) * 3.5- 5.5 40 mmol KCl per litre of sodium chloride. * ≥ 5.5 None.
Do not add prior to second IV fluid bag unless
K+ < 3.5.
Do not infuse KCl at more than 20mmol/hr
peripherally.
What is the requirement regarding glucose when treating DKA?
- When glucose is < 14 mmol / L continue sodium chloride 0.9% (+KCl) and ADD 10% glucose 125 mL / hour
What are the investigations and monitoring requirements for DKA?
- Baseline essential investigations
- U + E, urinalysis, VB glucose, FBC
- VBG for bicarbonate, potassium and pH
- ECG / CXR / MSU / blood cultures / pregnancy test f relevant
- Monitoring
- Reassess the patient hourly for the first 4-6 hours frequently and thereafter
- BP, HR, urine output, O2 sats
- Monitor capillary glucose and ketones hourly
- Monitor glucose, potassium, creatinine, bicarbonate, ketones and arterial gas if sats <92% (at 0hr, 1hr, 2hr, 4hr, 6hr, 12hr, 24hr)
What are the treatment targets for DKA?
- Blood glucose fall of >3 mmol/L/ hour until <14 mmol/L
- Capillary ketones fall of at least 0.5 mmol/L/hour until <0.6 mmol/L
- Venous bicarbonate rise of >3 mmol/L/hour until >15mmol/L
When can the patient be transferred to subcutaneous insulin?
- When well, able to eat and drink normally and venous pH >7.3 or blood ketones <0.6 mmol/L
What other points are important to be aware of for the management of patients with DKA?
- Critical care review may be required in the following presentations:
- Venous bicarbonate <5 mmol/L or pH <7.1
- Drowsy (GCS <12 or abnormal AVPU)
- Pregnant
- Heart failure
- Oliguria or anuria
- Sats <92% on air
- Persistent hypotension <90 systolic after 2L fluid
- Potassium <3.5 mmol/L on admission
- Cerebral oedema is a risk in young people and children therefore slower infusion of fluid may be required - protocol
- DKA is a prothrombotic state and VTE prophylaxis is critical
