T1 DM acute consequences

Question 1

Diabetic ketoacidosis

- Pathophysiology

Answer 1

Hyperglycaemia
- Due to insulin deficiency

Glucose leaks into urine

• Glycosuria
• Loss of electrolytes
• Leads to dehydration

Loss of fluid can cause kidney damage and lead to hypovolumemic shock

Increased lipolysis

• Increases FFA thus ketones
• High ketone levels causes acidosis by dissociating into H+ and anions.

Question 2

Physiological compensation of acidosis

Answer 2

Increased buffering
- H+/K+ pump

Respiratory compensation
- Hyperventilation

Renal excretion of H+
- Slow

Renal loss of Na+ and K+

Question 3

Diabetic ketoacidosis precipitating factors

Answer 3

Infections

Erroneous/ missed insulin

MI

Previously undiagnosed T1 DM

Drugs that increase glucose [e.g steroids]

Question 4

Diabetic ketoacidosis symptoms

Answer 4

Thirst, polyuria

Weakness, malaise

Drowsiness, confusion

Acidosis:

• Nausea
• Vommiting
• Abdominal pain
• Breathlessness

Question 5

Diabetic ketoacidosis clinical features

Answer 5

Usually young for T1 DM

Relative/ complete insulin deficiency

Normal/ low sodium

Low Blood glucose

Low bicarbonate

High serum ketones

Question 6

Management of diabetic ketoacidosis

Answer 6

Check and diagnose precipitating cause

Rehydrate/ monitor fluid balance

control glucose [insulin]

Monitor electrolytes

Prevention of clot
- LMW heparin

Access GCS

Decrease risk of aspiration if unconscious [NG tube?]

Question 7

Hyperosmolar hyperglycaemic state

Answer 7

Relative insulin deficiency

Insulin not high enough for lipolysis
- Glucose increases via increased hepatic glucose output

Hyperglycaemia increases osmotic diuresis

• Dehydration–> shock
• More profound in elderly/ weak

Question 8

Hyperosmolar hyperglycaemic state

- Clinical features

Answer 8

Usually older

Hypernatraemia

High glucose >40mmol/L

No ketone, normal pH

Increased risk of mortality compared to DKA

Corrected by correcting dehydration

Question 9

Management of Hyperosmolar hyperglycaemic state

Answer 9

Fluid replace but done cautiously [due to age of patient]
- Rehydration done with fluid balance monitored

Fluid administered too quickly = possible pulmonary oedema

Lower glucose with fixed insulin rate
- Only if glucose does not improve after fluids

Question 10

Hypoglycaemia in diabetes

Answer 10

Usually due to inappropiate insulin dosing

Symptoms

• Shaky
• Tachycardia
• Sweating
• Dizzy
• Anxiety
• Blurry vision, headache

Treatment
- Small treatment [sweet, sugary drink]

Question 11

Hypoglycaemic coma treatment

Answer 11

IM/ IV glucagon

IV dextrose

Question 12

Effects of insulin deficiency on adipose tissue

Answer 12

Increased lipolysis

Reduced esterification of fat

Hepatic synthesis of ketone bodies
- Ketosis occurs when ketone production exceeds its utilisation and clearance.

Question 13

Signs of diabeteic ketoacidosis

Answer 13

Hyperglycaemia and dehydration:

• Dry mouth
• Sunken eyes
• Postural/ supine hypotension
• Hypothermia
• Coma

Acidosis

• Facial flush
• Hyperventilation
• Ketone breath
• Ketouria

Question 14

Treatment of minor hypoglycaemic episode

Answer 14

20g carbohydrate sugary drink

Fruit juice

Glucose tablet

Glucose gel

Followed by starchy food