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Y5 Endocrine System > List I - Act Core Conditions > Flashcards

List I - Act Core Conditions Flashcards

1
Q

What is the definition of hypoglycaemia?

A
  • Blood glucose <4.0 mmol/L
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2
Q

How common is hypoglycaemia in people with type 1 diabetes mellitus?

A
  • People with type 1 diabetes mellitus experience around two episodes of mild hypoglycaemia per week
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3
Q

Which scale is used to classify hypoglycaemia?

A
  • The Edinburgh Hypoglycaemia Scale
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4
Q

What are the autonomic features of hypoglycaemia?

A
  • Sweating
  • Palpitations
  • Shaking
  • Hunger

General malaise

  • Headache
  • Nausea
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5
Q

What are the neuroglycopenic features of hypoglycaemia?

A
  • Confusion
  • Drowsiness
  • Odd behaviour
  • Speech difficulty
  • Incoordination
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6
Q

What are the medical risk factors for hypoglycaemia?

A
  • 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
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7
Q

What are the lifestyle risks of hypoglycaemia?

A
  • 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

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8
Q

What are the potential medical causes of inpatient hypoglycaemia?

A
  • 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
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9
Q

What are the potential reduced carbohydrate causes of inpatient hypoglycaemia?

A 
* 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
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10
Q

What is the management for hypoglycaemia in adults who are conscious, orientated and able to swallow?

A

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

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11
Q

What is the management for hypoglycaemia in adults who are unconscious and unable to swallow? (severe hypoglycaemia)

A
  • 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
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12
Q

How is mild hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?

A
  • 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
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13
Q

How is moderate hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?

A
  • 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
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14
Q

How is severe hypoglycaemia classified and treated in patients with diabetes according to the Leeds algorithm?

A
  • 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
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15
Q

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?

A
  • 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
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16
Q

What is important to be aware of regarding IM glucagon?

A
  • Should only be used once during treatment of a hypoglycaemic episode
  • Effect will wear off after 30 minutes
17
Q

If patients are already on a variable rate of IV infusion and experience hypoglycaemia, how should they be managed?

A
  • Reduce insulin infusion to 0.1 unit/hour
  • Treat hypoglycaemia
  • When blood glucose returns to >4mmol/L restore IV insulin to appropriate rate
18
Q

What is DKA?

A
  • Metabolic state characterised by the triad of:
  • Hyperglycaemia
  • Acidosis
  • Ketonaemia
19
Q

When should DKA be suspected?

A 
* 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

20
Q

What are the precipitating factors for DKA?

A
  • 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
21
Q

What is the diagnostic criteria for DKA?

A
  • 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

22
Q

What is the hospital management of DKA?

A

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

23
Q

What is the suggested IV fluid regime for DKA following initial treatment?

A
  • 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.
24
Q

What is the suggested management of KCl alongside fluid management for DKA?

A 
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.

25
Q

What is the requirement regarding glucose when treating DKA?

A
  • When glucose is < 14 mmol / L continue sodium chloride 0.9% (+KCl) and ADD 10% glucose 125 mL / hour
26
Q

What are the investigations and monitoring requirements for DKA?

A
  • 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)
27
Q

What are the treatment targets for DKA?

A
  • 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
28
Q

When can the patient be transferred to subcutaneous insulin?

A
  • When well, able to eat and drink normally and venous pH >7.3 or blood ketones <0.6 mmol/L
29
Q

What other points are important to be aware of for the management of patients with DKA?

A
  • 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

Y5 Endocrine System (2 decks)

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