W1L5 DKA & HHS Flashcards
Who gets DKA?
- Hallmark type 1 diabetes
- Previous undiag DM(25 – 30%)
- Interruption to normal insulin regime
- Intercurrent illness-usually infection
Diabetic Ketoacidosis:Pathophysiology
- N gluc in blood
- N Mecha
1. Insulin deficiency - lack gluc in ms
2. glucagon excess - increase gluconeogenesis
3. Rapid lipolysis(free fatty acids & ketone bodies)
4. Hypovolaemia–vomit+osmotic diuresis
Pathophysiology DKA detailed
- bl. gluc increase=hyperglycemia & glucosuria(water &Na loss)
- xinsulin=use fat=ketosis
- > ketone=metabolic acid=lactic acid by dehydration
- vomit(ileus)=worse dehy
- electrolyte abnor
- acidis=k ion enter circu=hyperkalemia
- phosphate deplete due meta aci
- dehy=
Precipitating Factors DKA
- New onset type 1 DM(25%)
- Infections(mos com coz)(40% )
- Drugs:Steroids, Thiazides, Dobutamine
- Omission Insulin(20%) due:
- Non-avail(poor country)
- fear ohypoglycemia
- rebel authority
- fear weight gain
- stress chronic disease
Symptoms and signs DKA
- Nausea
- Vomit
- Abd pain
- polyuria, polydipsia, weight loss
- Drowsiness/confusion/coma (severe)
- Kussmaul respiration - hyperventilation
- Sign asso sys ill(MI, infection, etc)
DIAGNOSIS DKA
Suspect: -Dehydration -Acidotic(Kussmaul’s)breathing w fruity smell (acetone) -Abd pain &\ distension -Vomit -Alter mental stat(disorientation to coma)
Diagnose:
- Hyperglycemia >300 mg/dl & glucosuria
- Ketonemia & ketonuria
- Metabolic acidosis= pH <7.2
Replacing fluids
Initial management:
-1L .9 Nacl(1/2, 1, 2, 4H)
Later(bl gluc <250mmol/L):
-10% dextrose w .9% N saline(125ml/h)
Insulin infusion
- 50U short act reg 50ml NaCl .9%
- Rate(0.1 unit/kg/hour) 70kg= 7U/h
- Aim serum HCO3(3 mmol/hr)/7.3 &/ HCO3>18
Replace electrolytes
- K+(mos imp)
- Insulin shift K+ into cell=rehydrate
- Serum K ≥ 5.5
- No potassium supplement
- Serum K 3.5-5.4
- Add 20mmol/l
- Serum K+ <3.5
- Add 40mmol/l
- Hyponatraemia due osmotic effect gluc= correct w ttt DKA
Monitoring
- Monitor uo & vital signs closely
- catheterize
- Repeat glucose, venous bicarbonate(ABG)
- 2–4h, 6-8h, 12h, 24h
- Repeat ABG at 2 hours if ximprove
- Alternative cause acidis(lactate)
Pitfalls in DKA
- High WCC (xinf)
- BUN(up w prerenal azotemia 2ry to dehydration)
- Cr(cross-react w ketone bod=xrenal fx)
- S Amylase=slh diag pancis
- Don’t stop insulin even bl gluc N
Complications DKA
- Cerebral Edema
- Intracranial thrombosis/infarction
- Acute tubular necrosis
- peripheral edema
HONK: Hyperosmolar hyperglycaemic state (HHS)
- Hallmark type 2 DM
- May occur:
- New diagnosis
- Poor compy w treatment
- Intercurrent illness (MI, Inf, CVA)
- Drugs(Steroids)
- Sugary drinks
Clinical Presentation HONK
- Possible osmotic symp
- Dehy 10L deficit
- Decreased lvl conci
- Sign inf up to 50%
- +/- thrombo-embolism up to 30%
- 2/3 undiagnosed
- 50% mortality
Diag HONK
- Bl gluc >600mg/dl
- Absence ketones
- Serum osmolality >350mmol
How do you calculate osmolality?
2(Na+K) + urea + glucose/18
Ttt HONK
1L 0.9% NaCl(1h, 2h, 4h, 8h)
Insulin:
- 50U actrapid 50ml w NaCl 0.9%
- Stop when recover(insulin sensitive)
Hypoglycaemia def
- Low plasma gluc conc that potential harm
- Plasma gluc alert value <70 mg/dL (<3.9 mmol/L), w/wo symp
Classification of Hypoglycemia ( ADA 2020)
Lvl 1= <=70mg/dl(3.9mmol/l)
Lvl 2= <54mg/dl(3.0mmol/l)
Lvl 3= no specific gluc threshold
Symptoms of hypoglycemia
Autonomic
-Trembling, palpitations, Sweat, Anxiety, Hunger, Nausea, Tingling
Neuroglycopenic
-Bad conc, Confusion, Weak, Drowsy, Vision change, Difi speak, Headache, Dizzy,
Tired
Risk factors for hypoglycaemia
- Insulin & sulfonylureas
- Old people
- Long duration diabetes
- Irregular eating habits
- Exercise
- Low HbA1c
- Fasting
- Hypoglycemia unawareness
- Alcohol
Hypoglycemia - Treatment
Mild-moderate:
- oral ingest 15g carb(gluc/suc tablet/solution)
- Wait 15min, retest BG & repeat if <70 mg/dl
- > 70 mg/dl snack is allowed
Severe:
- Comu: 1mg glucagon im & long act carb on recovery
- Hospital:
- I.M. glucagon 1mg
- I.V. 20ml of 50% dextrose
