Diabetes (Metabolic Complications) Flashcards

1
Q

What are the two major hyperglycaemic complications of diabetes?

A

Hyperglycaemic Hyperosmolar State

Diabetic Ketoacidosis

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2
Q

What is Hyperglycaemic Hyperosmolar State?

A

Severe hyperglycaemia with marked serum hyperosmolarity without evidence of significant ketosis

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3
Q

What is Diabetic Ketoacidosis?

A

Hyperglycaemia and acidosis caused by excessive ketones

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4
Q

What metabolic pathways underlie DKA?

A

Absence of Insulin causes hepatic glucose production/reduced peripheral uptake
Osmotic diuresis leads to dehydration
Lipolysis produces FFA –> Ketones
Ketones cause metabolic acidosis

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5
Q

What effect does the DKA have on the body?

A

Vomiting/electrolyte loss
Resp - Hyperventilation
Renal - Perfusion falls, impaired excretion of H+/ketones, Na/K loss

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6
Q

What is the effect on DKA on K levels?

A

Increased excretion of K
Initial serum K+ normal/elevated (pseudo-hyperkalaemia)
Due to extracellular migration of K+
Life threatening hypokalaemia may develop

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7
Q

What are the common causes of DKA?

A

Prev undiagnosed DM
Interruption of insulin therapy
Intercurrent illness/sugery

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8
Q

How does DKA present?

A
Prostration
Kussmal resp (air hunger)
N/V
Abdo pain
Confusion/stupor
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9
Q

What are the three key diagnostic criteria required for a diagnosis of DKA?

A

Acidaemia (pH <7.35) OR vHCO3- <15mmol/L
Hyperglycaemia (>11.1mmol/L) OR prev known DM
Ketonaemia - >3mmol/L OR >2+ in urine

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10
Q

What investigations are appropriated in suspected DKA?

A

U&Es, creatinine, BM
VBG (metabolic acidosis w/ raised anion gap)
ECG/CXR/cultures/preg test (clinical suspicion)

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11
Q

What determines the severity of DKA?

A

Blood pH

  • Mild <7.3
  • Mod 7.1-7.3
  • Sev <7.1
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12
Q

What is the immediate management of DKA?

A

ABCDE
1L 0.9% NaCl over 10mins if SBP >90 (500ml if <90)
IV insulin
-50 units ACTRAPID in 50ml 0.9% NaCl
-Start in syringe driver at 0.1 units/kg/hr

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13
Q

When should an urgent critical care review be sought?

A
Severe DKA
Drowsy
Pregnant
Sats <94% on 40% O2
Persistent hypotension (SBP <90 after 2L NaCl)
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14
Q

What non-immediate management should be considered in DKA?

A

Fixed rate insulin (0.1 units/kg/hr) + LA insulin
-aim BM fall of >3mmol/L/hr until <14mmol/L
Continue 0.9% NaCl
When BM <14mmol/L add 10% glucose (125mls/hr
If plasma K <5.4 add 40mmol KCL to 1L NaCl
Reassess every 4-6hrs

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15
Q

What management should be considered in DKA, once the pt is stable?

A

Transfer to SC insulin
Stop IV infusion
Refer to DM team

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16
Q

What is Hyperosmolar Hyperglycaemic State?

A

Severe hyperglycaemia causing a hyperosmolar state, in the absence of severe ketosis

17
Q

In which groups does HHS occur?

A

T2DM

Elderly

18
Q

What are the precipitating factors for HHS?

A

Consumption of G6 rich foods
Medications - Thiazides, steroids, b-blockers
Infection
MI

19
Q

How does HHS present?

A

Dehydration
Stupor/coma/seizures
Evidence of underlying illness

20
Q

How is a diagnosis of HHS confirmed?

A

Osmolality >320

-normal 280-295

21
Q

What is the immediate management of HHS?

A

IV NaCl (3-6L/12hrs)
Low dose, fixed dose IV Insulin
K+ replacement
Prophylactic LMWH

22
Q

How is HHS managed once the pt is stable?

A

Monitor - Vitals, fluids, glucose, osmolality, U&Es (hrly)
SC insulin
Refer to DM team

23
Q

What is Hypoglycaemia?

A

Plasma glucose <3mmol/L

24
Q

What are the two broad classifications of sx caused by Hypoglycaemia?

A

Autonomic

Neuroglycopenic

25
Q

What are the autonomic sx of Hypoglycaemia?

A
Sweating
Anxiety
Hunger
Tremor
Palpitations
26
Q

What are the neuroglycopenic sx of Hypoglycaemia?

A

Confusion
Drowsiness/Coma
Seizures

27
Q

What hormone does the pancreas release in response to Hypoglycaemia?

A

Glucagon

28
Q

What are the effects of Glucagon?

A

Increase glycogenolysis
Increase gluconeogenesis
Inhibit glycogen synthesis

29
Q

What about T1DM predisposes pts to Hypoglycaemia?

A

Insulin overdoses

a cells insensitive to falls in glucose, no glucagon released

30
Q

What are the causes of Hypoglycaemia?

A

Excess Insulin - Exogenous, insulinoma
Depletion of hepatic glycogen - malnutrition, fasting, exercise, alcohol, liver failure
Pituitary/adrenal insufficiency
Non-pancreatic neoplasms

31
Q

What is the management of non-severe Hypoglycaemia?

A

10-20g of fast acting carbohydrate (preferably liquid)
Recheck blood glucose after 10-15mins
If inadequate repeat & recheck
Sx improvement may lag behind, when sx improve give
LA carbohydrate

32
Q

What is the management of severe Hypoglycaemia?

A

IM glucagon
-500mg if <8yrs
-1g if >8yrs
If pt responds give LA carbohydrate

33
Q

When is glucagon not effective?

A

If alcohol has been consumed

34
Q

What is a common complication during recovery?

A

Vomiting

Can precipitate further hypos

35
Q

What can be used in hospital as an alternative to glucagon?

A

100ml of 20% glucose

Used up to 3 times