Red Book - Diabetic Emergencies

Question 1

What is DKA

Answer 1

Life threatening metabolic complication of DM

Triad of:

Ketonaemia

Hyperglycaemia

Acidaemia

Question 2

Pathophys of DKA

Answer 2

Relative or absolute insulin deficiency…

Increased glucagon, cortisol and catecholamines

—> lipolysis, free fatty acid production and ketogenesis

Ketoacids (3-b-hydroxybutyrate, acetone, acetoacetate) —> acidosis

Hyprglycaemia —> increased hepatic gluconeugenesis/glycolysis

Question 3

Why is there fluid depletion in DKA

Answer 3

Hyperglycaemia —> osmotic diuresis

Vomiting

Reduced oral intake (low GCS)

Question 4

Causes of DKA

Answer 4

Intercurrent infection
Not talking meds
MI
Surgery

Question 5

Features of DKA

Answer 5

Thirst
Polyuriea
N/V
Abdo pain
Dehydration
Ketotic smell
Kussmaul breathing

Confusion and coma

Question 6

Diagnosis of DKA

Answer 6

Capillariy glucose > 11 mmol/L

Ketonaenmia > 3mmol/l OR 2+ urine dip

Venous bicarb < 15mmol/L OR pH<7.3

Question 7

Commonest cause of death in DKA

Answer 7

Cerebral oedema (worse in children/young adults)

Question 8

When would you consider admission to HDU/ITU

Answer 8

Ketones>6
Bicarb < 5
pH<7.1
Low K < 3.5
GCS < 12
SpO2 < 92%

Systolic BP < 90
HR <60 or > 100

Anion gap >16

Question 9

Treatment goals

Answer 9

Decrease ketones by 0.5mmol/l per hour

Increase bicarm by 3mmol/l per hour

Decreased Cap BM by 3mmol/l per hour

Maintain K

Question 10

What are the broad headings of treatment in DKA

Answer 10

ABCDE and treat etc…

Fluid and electrolyte management

Insulin and metabolic correction

Treat the cause

Supportive care

Question 11

Describe the fluid and electrolyte tx

Answer 11

AIm to restore volume and clear ketones, and correct imbalances

Saline is fluid of choice

Give 500ml bolus if BP<90

Further fluids over 1-4 hours depending on policy

When potasssium less than 5.5, supplement with K

Question 12

Insuline therapy

Answer 12

Fixed rate infusion - 0.1 unit/kg/hr

DO NOT BOLUS

Continue long acting insulin

Regular venous bloods and urine/blood ketones

If they hypo - 10% glucose

Question 13

Supportive care

Answer 13

VTE prophylaxis - mechanical/pharma
Stress ulcer
Enteral feed

Question 14

How does management differ in kids

Answer 14

Markedly increased risk of cerebral oedema

Bolus fluid in shocked patietns
Work out fluid requirements and deficit and replace
Maintenannce fluid needs are lower

Delay insulin for 1 hour

Question 15

What is HHS

Answer 15

Hyperglycaemic hyperosmolar state

Severe hyperglycaemia with fluid depletion

No/mild ketosis

Found in elderly with type II DM

Question 16

Mortality of HHS

Answer 16

15-30%

Much higher than DKA

Question 17

Features of HHS

Answer 17

Hypovolaemia — Significant losses (100-220ml/kg)

Hyperglycaemia (MARKED>30)
Without ketone
Without acidosis

Serum hyperosmolarity
>320mosmol/kg

Question 18

Goals of treatment HHS

Answer 18

Treat underlying cause
Normalise osmolality
(2xNa + glucose +urea)

Replace losses

0. 9% saline +/- potassium
0. 45% if osmolality not falling

Replace K is <5.5

Normalise BM

Prevent complications

Question 19

Targets for treatment HHS

Answer 19

K 4.0 to 5.5
Na reduces by <10mmol/l in 24 hours

Glucose fall by 5mmol/L per hour

Question 20

Glucose normalisation

Answer 20

Fluid should do it

If glucose stops falling —> insulin fixed at 0.05units/kg/hour

Question 21

When to admit HHS to ITU

Answer 21

Osm>350

Na > 160

pH < 7.1

High or low K

GCS < 12

SpO2 < 92%
HR <60 or > 100

U/O less than 0.5ml/kg/hr
Creatinine > 200 umol/l

Hypothermia

MI, Stroke or comorbidity