T1 L17 Acute complications of diabetes

Question 1

What is diabetic ketoacidosis?

Answer 1

Insulin deficiency leading to ketosis and acidosis

Question 2

What are the general effects of insulin deficiency?

Answer 2

Glycogenolysis in the liver by glucagon, adrenaline and cortisol
Lipolysis and reduced esterification of fatty acids in adipose tissue
Proteolysis and reduced uptake of amino acids in the muscle
Increased hepatic glucose output and hyperglycaemia

Question 3

What is the pathophysiology of DKA?

Answer 3

Unchecked gluconeogenesis –> hyperglycaemia
Osmotic diuresis –> dehydration
Unchecked ketogenesis –> ketosis
Dissociation of ketone bodies into hydrogen ion and anions leading to anion-gap metabolic acidosis

Question 4

When does ketoacidosis occur?

Answer 4

When ketone body production exceeds the rate of utilising in peripheral tissues and renal clearance

Question 5

Describe what happens in adipose tissue during DKA

Answer 5

Increased lipolysis and reduced esterification of fat causes excess FFA and glycerol
FFA are a substrate for hepatic synthesis of ketone bodies

Question 6

How is the acidosis in DKA managed by the body?

Answer 6

Intracellular buffering - H/K exchange
Respiratory compensation - hyperventilation
- the H+ stimulate the respiratory centres to breath out more CO2

Question 7

Describe the electrolyte disturbances in DKA

Answer 7

Potassium depletion

Sodium depletion leading to dehydration

Question 8

What is the common group for DKA?

Answer 8

Mostly young T1DM

Question 9

What are the precipitating causes of DKA?

Answer 9

Infections - pneumonia, UTI, viral illness, gastroenteritis
Error / missed insulin administration
Myocardial infarction
Previously undiagnosed type 1 diabetes
Drugs - steroids

Question 10

What is the serum sodium in DKA?

Answer 10

Normal or low

Question 11

What is the blood glucose in DKA?

Answer 11

< 40mmol/l

Question 12

What is the serum bicarbonate and pH in DKA?

Answer 12

<14mmol/l

<7.3

Question 13

What is the serum ketones in DKA?

Answer 13

Positive

Question 14

What are the symptoms and signs caused by hyperglycaemia and dehydration in DKA?

Answer 14

Thirst and polyuria
Weakness and malaise
Dehydration and confusion
Dry mouth and sunken eyes
Postural or supine hypotension
Hypothermia or coma

Question 15

What are the symptoms and signs caused by acidosis in DKA?

Answer 15

Nausea and vomiting
Abdominal pain
Breathlessness
Facial flush
Hyperventilation
Smell of ketones on breath and ketonuria

Question 16

What is the management plan in DKA?

Answer 16

1) Confirm diagnosis and check for precipitating causes
2) Rehydrate and monitor fluid balance - IV fluids (saline with added K), urinary catheter
3) Lower glucose - IV insulin
4) Monitor electrolytes - K and Na
5) Prevent clots - give low molecular weight heparin

Question 17

What is hyperosmolar hyperglycaemia state?

Answer 17

Relative insulin deficiency –> hyperglycaemia –> dehydration

Question 18

Why is there no breakdown of fats in HHS?

Answer 18

There is enough insulin still present

Question 19

What is the common group for HHS?

Answer 19

Usually above 40 years

Question 20

What are the precipitating causes of HHS?

Answer 20

Previously undiagnosed, steroids, diuretics, sugar

Question 21

What is the serum sodium in HHS?

Answer 21

Usually high

Question 22

What is the blood glucose in HHS?

Answer 22

Often >40mmol/l

Question 23

What is the serum bicarbonate and pH in HHS?

Answer 23

Normal

7.4

Question 24

What is the serum ketones in HHS?

Answer 24

0

Question 25

What is the management in HHS?

Answer 25

Confirm diagnosis and check for precipitating causes
Rehydrate and monitor fluid balance
Lower glucose once glucose isn’t improving with fluids by giving IV insulin
Monitor electrolytes
Prevent clots

Question 26

What is hypoglycaemia?

Answer 26

Blood sugar < 4mmol/l

Question 27

Why does the clinical syndrome associated with hypoglycaemia develop?

Answer 27

The nervous system becomes glucose deficient or neuroglycopaenic

Question 28

What are the causes of hypoglycaemia?

Answer 28

Insulin
- inappropriately excessive doses
- not eating or insufficient carbohydrates
Sulfonylureas

Question 29

What are the autonomic symptoms of hypoglycaemia?

Answer 29

Sweating, feeling hot
Trembling or shakiness
Anxiety
Palpitations

Question 30

What are the neuroglycopenic symptoms of hypoglycaemia?

Answer 30

Dizziness, light headedness
Tiredness
Hunger, nausea
Headache
Inability to concentrate, confusion, difficulty speaking, poor concentration, behavioural changes, automatism
Coma and convulsions, hemiplegia

Question 31

What is the counter-regulation in hypoglycaemia?

Answer 31

Glucagon, adrenaline, cortisol and GH have anti-insulin effects
Glucagon stimulates glycogenolysis and gluconeogenesis

Sympathetic nerves may directly activate hepatic glycogenolysis and stimulate glucagon secretion

Question 32

What is the treatment for a minor episode of hypoglycaemia?

Answer 32

20g carbohydrate as sugary drink, fruit juice, glucose tablets
Glucose gels

Question 33

What is the treatment for a hypoglycaemic coma?

Answer 33

IM or IV glucagon 1mg

IV dextrose 25g (150ml, 10% glucose)

Question 34

What would you give to treat DKA?

Answer 34

Insulin, fluids and potassium