Pt w/ Glucose disturbance

Question 1

In which group of patients does DKA occur?

Answer 1

T1DM

Question 2

What are the clinical features of DKA?

Answer 2

VARIABLE

• Polyuria and Polydipsia are important hx factors (has lead to dehydration over past few days)
• Weight loss and weakness
• Hyperventilation - respiratory compensation for the metabolic acidosis - Kussmaul’s respiration (deep and sighing)
• Abdominal pain (DKA can be an acute abdomen)
• Vomiting (this makes dehydration worse)
• Confusion and coma
• Signs of dehydration
• Sweet smelling breath

Question 3

What investigations should you do if you’re considering DKA?

Answer 3

BLOOD GLUCOSE (usually high but might be low in severe academia)
ABG - assess degree of acidosis 
U&E
Urinalysis - ketones strongly positive. Ketones may be positive in normal individuals after period of starvation 
FBC - WCC might be up 
Septic screen (urine and blood cultures)
Plasma ketones 
CXR

Question 4

What is required for diagnosis of DKA?

Answer 4

Positive urinary or blood ketones AND arterial pH <7.30 and/or serum bicarbonate <15mmol/L

Question 5

What are some common precipitants of DKA?

Answer 5

Infection, non-compliance with treatment, Newly diagnosed

Question 6

What are the two main principles of DKA management?

Answer 6

REHYDRATION AND INSULIN THERAPY

Question 7

Describe DKA management

Answer 7

Place 2 wide bore cannulas and start fluid replacement through one (0.9% NaCl)
- if HYPOTENSIVE give bolus (500mL over 10-15mins)
- then consider 2hrly or 3hrly 1L bags of NaCl + POTASSIUM REPLACEMENT
INSULIN THERAPY
Consider arterial line for regular ABGs
Treat infection

Question 8

Why do we need to replace potassium in DKA management? How do we do it?

Answer 8

It will shift into intracellular compartment under influence of Insulin
- do not give potassium replacement in first litre or if serum potassium is >5.5mmol/L but consider giving after

Question 9

Insulin therapy in DKA

Answer 9

IV insulin infusion pump (50U soluble insulin added to 50mL 0.9% NaCl)
At a rate of 0.1U/kg/h
Should aim for capillary glucose drop of 5mmol/h - if this is not being achieved then increase infusion rate by 1U/h

Question 10

What should you monitor throughout DKA management?

Answer 10

Cap glucose, ketones and urine output, VBG

Question 11

How long do we give IV insulin therapy for in DKA? What do we do when it is done?

Answer 11

Until capillary ketones <0.3, venous pH >7.3 and venous bicarbonate is >18 (urinary ketones take longer to clear)

If these are all achieved then change to SC insulin regimen and stop IV pump 1-2hrs after

Question 12

What complications are associated with DKA treatment?

Answer 12

Hypoglycaemia from over-treatment with insulin
Cerebral oedema - occurs mainly in children - precipitated by major shifts in blood biochemistry during treatment
Serum phosphate can fall (moves IC with K+)
Serum Mg can fall
Hyperchloraemic acidosis can occur
thromboembolism

Question 13

Who should be assessed for hypoglycaemia?

Answer 13

ALL PATIENTS SHOULD HAVE BLOOD GLUCOSE CHECKED especially…

• those with collapse or reduced consciousness
• those with infection

ALL UNCONSCIOUS PATIENTS SHOULD BE ASSUMED TO BE HYPOGLYCAEMIC UNLESS PROVEN OTHERWISE

Question 14

What glucose levels would suggest hypoglycaemia

Answer 14

Glucose <4mmol/L
ALWAYS TAKE A CAPILLARY SAMPLE and then confirm with the LAB
Lab sample <2.2mmol/L is defined as SEVERE ATTACK

Question 15

How does hypoglycaemia present?

Answer 15

The sympathetic system becomes overactive leading to:

• Tachycardia
• Hypertension
• Shaking
• Sweating
• Anxiety
• Pallor
• Palpitation

When it becomes severe (plc <2.6mmol/L) the symptoms might include:

• Confusion
• Slurred speech
• Focal neurological deficit
• Coma

Question 16

In which patient might symptoms of hypoglycaemia not be so clear?

Answer 16

Patients w/ well controlled diabetes have hypoglycaemia more frequently and so might not be symptomatic as soon
Patients on Btea-blockers. These drugs could mask symptoms

Question 17

What investigations should be done in a hypoglycaemic patient?

Answer 17

GLUCOSE
U&Es (hypoglycaemia is common in diabetic nephropathy)
Take C-peptide and serum insulin levels
Always take blood BEFORE giving insulin

Question 18

What are some causes of hypoglycaemia?

Answer 18

T2DM on sulphonylureas common 
(but basically any diabetic drug that is overused - not metformin)
Hypopituitarism
Acute liver failure ALCOHOL
Adrenal failure 
Myxoedema 
Sepsis syndrome 
Malaria 
Insulinoma

Question 19

Management of hypoglycaemia

Answer 19

Take blood PRIOR to glucose administration (glucose, insulin, C-peptide)
- Give IV thiamine if alcohol intake or malnourishment
- 50g ORAL GLUCOSE IF CONSCIOUS or Lucozade and a starchy snack
OR
- 50mL of 50% glucose IV (in unconscious or uncooperative)
OR
- 1mg GLUCAGON IM then give oral glucose (if IV access not possible)
ADMIT

Question 20

What response should you see to treatment of hypoglycaemia?

Answer 20

Patient should regain consciousness or become coherent within 10mins although complete recover may take up to 45min
DO NOT GIVE FURTHER BOLUSES WITHOUT REPEATING BLOOD GLUCOSE