Hpyerglycemia

Question 1

DKA

Answer 1

Diabetic keto-acidosis

Question 2

What is DKA

Answer 2

It occurs when the body produces high levels of blood ketones in response to its inability to produce or use insulin

Question 3

HHS

Answer 3

Hyperosmolar hyperglycaemic state

Question 4

HONK

Answer 4

hyperosmolar non- ketotic state

Question 5

what is HONK

Answer 5

A very high blood glucose level causes severe dehydration and elevated blood osmolality without significant ketoacidosis

Question 6

to convert from mg/dL to mmol/L

Answer 6

divide by 18

Question 7

calculate correct Na

Answer 7

Add 1.6 to Na level for each 6mmol/L glucose above 6

Question 8

Pathophysiology of DKA

Answer 8

-is caused by absolute or relative decrease in insulin levels.
-Plasma glucose increase causes an osmotic diuresis, with Na + and water loss (up to 8–10L), hypotension, hypoperfusion, and shock.
-Normal compensatory hormonal mechanisms are overwhelmed and lead to an increase in lipolysis.
-In the absence of insulin this results in the production of non-esterified fatty acids, which are oxidized in the liver to ketones.
-Younger undiagnosed diabetics often present with DKA developing over 1–3 days. Plasma glucose levels may not be grossly increased; euglycaemic ketoacidosis can occur.

Question 9

pathophysiology of HONK

Answer 9

-It is caused by intercurrent illness, inadequate diabetic therapy and dehydration.
-It develops over days/weeks, and is more common in the elderly.
-HHS is characterized by an increase in glucose levels (> 30mmol/L), increased blood osmolality, and a lack of urinary ketones.
-Mortality is 85–10 %, but may be even higher in the elderly.

Question 10

in which type diabetes does HONK occur

Answer 10

type 2

Question 11

symptoms of DKA

Answer 11

dehydration
thirst
polydipsia
polyuria
decreased skin turgor
dry mouth
hypotension
tachycardia

Question 12

GI symptoms of DKA

Answer 12

nausea
vomitting
abdominal pain

Question 13

Hyperventilation in DKA

Answer 13

(respiratory compensation for the metabolic acidosis) with deep rapid breathing (Kussmaul respiration) and the smell of acetone on the breath

Question 14

altered mental status in DKA

Answer 14

True coma is uncommon, but altered conscious states and/or focal neurological deficits (which may correct with treatment) are seen particularly in older patients with HHS or patients with severe DKA.

Question 15

common underlying conditions of DKA: the four Is

Answer 15

Infection: common primary foci are urinary tract, respiratory tract, skin. (sepsis, pancreatitis)

Infarction: myocardial, stroke, GI tract, peripheral vasculature.
(ACS)

Insufficient insulin.

Intercurrent illness: many underlying conditions precipitate or aggravate DKA and HHS, as mentioned above. (CVA)

Question 16

Differential diagnosis of DKA

Answer 16

Acute Pancreatitis
Alcoholic Ketoacidosis
Appendicitis
Cystitis in Females
Hyperosmolar Coma
Hypophosphatemia
Hypothermia
Lactic Acidosis
Metabolic Acidosis
Salicylate Toxicity
Septic Shock

Question 17

immediate management

Answer 17

-Stabilise patient using the ABCs approach
If altered consciousness/coma is present, provide and maintain a patent airway.
-Assess breathing and circulation. High flow O2 if hypoxic.
-Assess blood pressure and circulation. Establish IV access. Immediate fluid bolus if circulation impaired (use crystalloid);
-Assess level of consciousness, check glucose stat and 2 hourly.
-Expose patient enough to be able to do a thorough assessment, but minimize heat loss.

Question 18

Fluid management

Answer 18

Fluid boluses of 0.9% Saline (20-30ml/kg) till systolic blood pressure above 90.

If glucose drops below 15mmol/L change to 1L 5% Dextrose containing fluid (Rehydration Solution) 6 Hourly

Question 19

fluid management in HHS

Answer 19

Consider changing to 0.45% Saline if glucose and osmolality not declining despite usual regime above.

Question 20

drug treatment

Answer 20

insulin
electrolyte replacement

Question 21

when to start insulin

Answer 21

Patients is resuscitated to a systolic blood pressure of at least 90.

Potassium level is known and relative or absolute potassium deficit is being addressed with potassium replacement

Question 22

administration of insulin

Answer 22

Start an infusion of soluble insulin using an IV pump or paediatric burette at 6U/hr (50 units Actrapid in 200ml 0.9% Saline, run at 24ml/hour). No loading dose is required.

If no rate minder is available
10 units Actrapid subcutaneously stat, then 6 units subcutaneously hourly

Check plasma glucose levels every hour initially.
Keep infusion rate constant, but change to 5% Glucose containing solution once glucose level falls below 15mmol/L.

Question 23

electrolyte replacement

Answer 23

Although total body K + is low, plasma K + may be normal, increased or decreased.

With treatment, K + enters cells and plasma levels decrease: therefore, unless initial K + levels are > 5mmol/L, give K+

Question 24

other electrolytes

Answer 24

Other electrolytes such as Ca2+, Mg2+, and PO42– are commonly disturbed, but rarely need emergency correction.

Bicarbonate administration has not been shown to improve mortality or morbidity. Has been shown to worsen the ketosis and delays ketone clearance. Only consider if patient has been fully resuscitated to a systolic blood pressure above 90mmHg and the pH is below 7. Consider an NG tube to decrease risk of gastric dilation and aspiration.

Question 25

adjunctive treatment

Answer 25

antibiotics
supportive management

Question 26

antibiotics

Answer 26

Not for routine administration.
If infective focus found administer per suspected organism.
Consider empiric broad spectrum antibiotics if pH remains below 7 or the patient is not responding to treatment.

Question 27

supportive management

Answer 27

Monitor urine output (most accurate with urinary catheter).

If patient is drowsy/decreased level of consciousness give DVT prophylaxis.
Arrange admission to ICU, HDU, or acute medical admissions unit.

Question 28

normal glucose

Answer 28

<11 mmol/L

Question 29

normal bicarbonate

Answer 29

> /= to 18

Question 30

normal ph

Answer 30

> 7.3

Question 31

normal anion gap

Answer 31

<12

Question 32

investigations

Answer 32

Check blood glucose and ketone levels and test the urine for glucose and ketones.

Send blood for U&E, blood glucose, creatinine, osmolality (or calculate it):
mOsm/L= (2 × Na + ) + glucose (mmol/L) + urea (mmol/L).

Check Venous Blood Gas (look for metabolic acidosis ± respiratory compensation).

FBC

CXR (to search for pneumonia).

ECG and cardiac monitoring (look for evidence of hyper/hypokalaemia).

If infection/sepsis suspected, as appropriate:
-Blood cultures
-Throat or wound swabs
-Urine/sputum microscopy and culture.