DIABETIC EMERGENCIES Flashcards
What are the 3 criteria for a diagnosis of DKA? Include numbers
- Ketones >3mmol/L
- Blood glucose >11mmol/L
- HCO3-<15mmol/L/ pH<7.3
Name the 9 circumstances in DKA that may lead to admission to ITU in a patient wth DKA?
- Ketones >6
- HC03-<5
- pH<7.1
- Hypokalaemia
- GCS<12
- tachy or bradycardia
- SBP<90
- O2 sats <92
- Organ failure
What are he principles of IV insulin therapy in DKA?
- Start continuous fixed rate IV infusion via an infusion pump. 50 units human soluble Insulin (Actrapid) made up to 50ml with 0.9% NaCl solution. Infuse at a fixed rate of 0.1unit/kg/hr (i.e. 7ml/hr if weight is 70kg).
- Maximum initial rate of 15 units/hr is recommended.
- If the patient normally takes a long or intermediate acting insulin (e.g. Levemir, Lantus, Toujeo, Tresiba, insulitard, Humulin I), continue the basal rate at usual dose and time. Avoid hypoglycaemia. Consider increasing the IV 10% glucose rate and reducing the IV 0.9% NaCl rate
What are the principles of potassium management in DKA?
Potassium replacement in mmol/l
- Over 5.5= Nil
- 3.5-5.5= 40mmol KCL per litre as per fluid protocol except for the first saline (1 hour) bag
- Below 3.5= 40 mmol KCL per litre (Senior review, as additional K needed. Consider central line insertion)
What are the principles of 0.9% NaCl therapy in DKA?
- If SBP <90 mmHg give 500 ml of 0.9% NaCL over 10-15 minutes. If SBP remains below 90mmHg this may be repeated.
If SBP>90 mmHg give: 0.9% NaCl 1L over 1st hr (no KCL)
- 9% NaCl 1L with KCl over next 2 hrs (Check K+)
- 9% NaCl 1L with KCl over next 2 hrs (Check K+)
- 9% NaCl 1L with KCL over next 4 hrs (Check K+) 0.9%
NaCl 1L with KCL over next 4 hrs (Check K+)
What are the principles of glucose therapy in DKA?
When glucose falls below 14 mmol/L or in non-hyperglycaemic DKA presenting with CBG <14mmol/L, commence 10% glucose given at 125ml/hr. It is important to continue 0.9% NaCl solution to correct circulatory volume (Infuse 0.9% NaCl in separate cannula)
What are the minimum expected drops per hour in
- ketones
- venous bicarb
- CBG
- If capillary ketones measurement is not falling by at least 0.5 mmol/l/hr
- OR venous bicarbonate not rising by at least 3mmol/L/hr
- OR CBG not falling by at least 3mmmol.L/hr
Increase insulin infusion rate by 1 unit/hr increments hourly until ketones falls at target rate
When can DKA be considered over?
- Ketones <0.6 (ideally <0.3)
- Bicarb >18
- pH>7.3
- anion gap <10
What are the principles of management of HHS?
- Fluid resuscitation is usually sufficient
- Aim to replace 50% of estimated losses in first 12 hours and the remaining in the next 12 hours. Please take into account any significant comorbidities. (Aim for NO > 10mmol/l/24 hr drop in Na)
- use NaCl 0.9% 1L over 1 hour (over 30 min if SBP<90 +safe to do)
- 1L over 2 hours
- 1L over 3 hours
- 1L over 4 hours
- 1L over 6 hours
What dose of insulin can be administered and under what circumstances in HHS?
Fixed rate insulin infusion (50 units actrapid+ 50ml 0.9%NaCl) at a rate of 0.05 units/kg/hr, should be commenced once the blood glucose is no longer falling with IV fluids alone (after 2nd bag), OR, immediately if there is significant ketonaemia.
What is the management of a hypo in a patient who is conscious, oriented and able to swallow? How often should CBG monitoring be? How many times can this be repeated?
Oral glucose
- 15-20g of fast acting carbs
Every 15 minutes
4 times
What is the management of a patient who is conscious, not oriented and able to swallow?
- 2 tubes of glucogel
- or
- 1mg IM glucagon
What is the management of a severely confused disorinted patient who is unable to swallow?
- 1mg IM glucagon-> when blood glucose has recovered to >4 give 15-20mg of long acting carbs
- 100ml of 20% IV dextroseover 10-15 minutes in a large vein with a large flush
