T1 L17 - Acute complications of diabetes

Question 1

what are the 3 things you should know by the end of this

Answer 1

• Diabetic keto-acidosis
• Hyperosmolar hyperglycaemic state
• Hypoglycaemia

Question 2

give a quick overview of diabetic keto-acidosis

4 marks

Answer 2

1 a)Unchecked gluconeogenesis- Hyperglycaemia

b)Osmotic diuresis- Dehydration

2 a)Unchecked ketogenesis - Ketosis

b)Dissociation of ketone bodies into hydrogen ion and anions - Anion-gap metabolic acidosis

Question 3

what are the physiological effects of insulin deficiency on adipose tissue

(4marks)

Answer 3

Increased lipolysis and reduced esterification of fat​
-Insulin deficiency​
-Glucagon/adrenaline excess ​
Results in excess FFA and glycerol from breakdown triglycerides​

FFA substrate for hepatic synthesis of ketone bodies​

• Acetoacetate/Hydroxybutyrate – strong organic acids​
• (Acetone) ​
• Rate of ketogenesis is linked to rate of gluconeogenesis​

Muscle and brain can utilise ketones as main energy substrate​

Ketoacidosis results when ketone body production exceeds rate of utilisation in peripheral tissues (brain and muscle) and renal clearance

Question 4

quick overview of how you would manage diabetic ketoacidosis

Answer 4

Giving lots of glucose
insulin
fluid
electrolytes

Question 5

Managing diabetic ketoacidosis

Answer 5

1)Acidosis managed by​

-Intracellular buffering - H+ / K+ exchange​
Potassium hydrogen ion pump​

-Respiratory compensation – hyperventilation​
H+ stimulates respiratory centres​
Breathe off CO2 (H+ + HCO3- H2O + CO2)​

-Renal excretion of H+ (slow response)​

2) Electrolyte disturbances – renal losses​
- Potassium depletion – maybe >250mmol​
- Sodium depletion -​
- dehydration​

Question 6

clinical features of diabetic ketoacidosis

Answer 6

Mostly young

relative/absolute insulin deficiency

blood glucose<40mmol/l

Question 7

precipitating factors for diabetic ketoacidosis

Answer 7

• Infections – pneumonia, urinary tract, viral illnesses, gastroenteritis​
• Error/ missed insulin administration​
• Myocardial infarction​
• Previously undiagnosed Type 1 diabetes​
• Drugs: steroids​
• Unidentified ​

Question 8

what are the symptoms and signs of diabetic ketoacidosis

Answer 8

Symptoms​
Cause​
Signs​

1)Thirst and polyuria ​
Weakness and malaise​
Drowsiness, confusion​

Hyperglycaemia + dehydration​
Dry mouth, Sunken eyes​
Postural or supine hypotension​
Hypothermia & Coma​

2)Nausea and vomiting​
Abdominal pain​
Breathlessness​

Acidosis​

Facial flush​
Hyperventilation​
Smell of ketones on breath and ketonuria​

Question 9

look at case

Answer 9

how was it?

Question 10

what does HHS stand for

Answer 10

Hyperosmolar Hyperglycaemic State

Question 11

what is the pathophysiology of HHS

Answer 11

Insulin so no lipolysis, but not enough to stop high glucose causing u to pee out glucose, so you become dehydrated ​
​
So much so that you require 20 plus litres of water in order to restore body electrolyte fluid balance ​
​
Usually in frail elderly ppl

Question 12

what are the clinical features of HHS

Answer 12

Age​
Usually >40years​
Precipitating causes​
previously undiagnosed, steroids, diuretics, sugar​
Serum sodium​
Usually high​
Blood glucose​
Often >40mmol/l​
Serum bicarbonate/pH​
Normal / pH 7.4​
Serum ketones​
0​
Mortality​
30% (thromboses)​
Subsequent course​
Diet/tablet controlled​

usually those with T2 diabetes

Question 13

look at case history for HHS

Answer 13

how did it go

Question 14

Apart from giving fluid to correct dehydration in HHS what else can you do (in elderly fluids must be given slowly to correct )

Answer 14

Rehydrate & monitor fluid balance​
Iv fluids - saline with added potassium​
Consider urinary catheter​
Lower glucose (once glucose not improving with fluids)​
Intravenous insulin – fixed rate 0.05Unit/kg/hr​
Monitor electrolytes​
Potassium (and sodium)​
Prevent clots​
Treatment low molecular weight heparin​
​
Patients are often elderly and severely ill.​

Question 15

what are the symptoms of Hypoglycaemia (hypo)​

Answer 15

tachycardia

sweating

dizzy

anxious

hungry

Question 16

define the state of hypo

Answer 16

Hypoglycaemia is a biochemical term and exists when blood sugar < 4mmol/l but is often used to describe a clinical state. The clinical syndrome associated with hypoglycaemia develops as the nervous system becomes glucose deficient or ‘neuroglycopaenic’. It can be classified:​

Question 17

split the symptoms into autonomic (sympathomedullary activation )

&

Neuroglycopenic

Answer 17

-Autonomic – sympathomedullary activation​

Sweating, feeling hot​
Trembling or shakiness​
Anxiety​
palpitations​

-Neuroglycopenic​
Dizziness, light-headedness​
Tiredness​
Hunger, nausea​
Headache​
Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism​
Coma and convulsions, hemiplegia​

Question 18

what are the causes of hypoglycaemia

Answer 18

Insulin​
Inappropriately excessive doses​

Not eating, or insufficient carbohydrate​
Sulfonylureas​

Question 19

how does the body usually handle hypo

Answer 19

-Glucagon, adrenaline, cortisol and GH all have ‘anti-insulin effects’​
Glucagon stimulates glycogenolysis and gluconeogenesis and is probably primary response​
Adrenaline increases glycogenolysis​
GH and cortisol limit glucose disposal in peripheral tissues, but this effect takes several hours so of little benefit acutely​

-Sympathetic nerves may also directly activate hepatic glycogenolysis and stimulate glucagon secretion​
​

Question 20

how do you treat minor and major hypoglycaemic episodes

Answer 20

-Minor episodes​
20g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something ‘starchy’ to eat​
Glucose gels​
​
-Hypoglycaemic coma​
im or iv Glucagon 1mg​
iv dextrose 25g  (150ml 10% glucose)​