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Year 2 Medicine > Acute Complications of Diabetes > Flashcards

Acute Complications of Diabetes Flashcards

1
Q

What is Diabetic keto-acidosis? (DKA)

A
  • Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes and, much less commonly, of type 2 diabetes.
  • DKA happens when your blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body
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2
Q

DKA is more common in which type of diabetes?

A

Type 1

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3
Q

What is Hyperosmolar hyperglycaemic state? (HHS)

A

Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.

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4
Q

Which is rarer, DKA or HHS?

A

HHS

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5
Q

Diabetic Ketoacidosis: Pathophysiology

  • Unchecked gluconeogenesis -> …
  • Osmotic diuresis -> …
  • Unchecked ketogenesis -> …
  • Dissociation of ketone bodies into hydrogen ion and anions -> …-gap metabolic …
  • Often a precipitating event is identified (such as?..)
A
  • Unchecked gluconeogenesis -> Hyperglycaemia
  • Osmotic diuresis -> Dehydration
  • Unchecked ketogenesis -> Ketosis
  • Dissociation of ketone bodies into hydrogen ion and anions -> Anion-gap metabolic acidosis
  • Often a precipitating event is identified (infection, lack of insulin administration)
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6
Q

Diabetic ketoacidosis- metabolic derangement

Acidosis managed by

  • Intracellular … - H+ / K+ exchange
    • Potassium hydrogen ion pump
  • Respiratory compensation – how?
    • H+ stimulates … centres
    • … off … (H+ + HCO3- H2O + CO2)
  • … excretion of H+ (slow response)

Electrolyte disturbances – renal losses

  • Potassium … – maybe >250mmol
  • Sodium …
  • …
A

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)

Electrolyte disturbances – renal losses

  • Potassium depletion – maybe >250mmol
  • Sodium depletion -
  • Dehydration
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7
Q

Diabetic Ketoacidosis - Clinical Features

  • Age - Mostly … with Type … DM
  • Precipitating causes - Relative or absolute … deficiency
A
  • Age - Mostly young T1DM
  • Precipitating causes - Relative or absolute insulin deficiency
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8
Q

Diabetic ketoacidosis - Precipitating factors

  • Infections - such as … (3)
  • Error/ missed … administration
  • Myocardial infarction
  • Previously undiagnosed …
  • Drugs: such as …
  • Unidentified
A
  • Infections - pneumonia, urinary tract, viral gastroenteritis
  • Error/ missed insulin administration
  • Myocardial infarction
  • Previously undiagnosed Type 1 diabetes
  • Drugs: Steroid
  • Unidentified
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9
Q

Diabetic Ketoacidosis - Signs and Symptoms

If the cause is Hyperglycaemia + dehydration, symptoms will be…

  • Thirst and …
  • Weakness and …
  • Drowsiness, …

Signs will be:

  • … mouth, … eyes
  • … or … hypotension
  • Hypothermia & …
A

If the cause is Hyperglycaemia + dehydration, symptoms will be…

  • Thirst and polyuria
  • Weakness and malaise
  • Drowsiness, confusion

Signs will be:

  • Dry mouth, Sunken eyes
  • Postural or supine hypotension
  • Hypothermia & Coma
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10
Q

Diabetic Ketoacidosis - Signs and Symptoms

If the cause is acidosis, symptoms will be…

  • Nausea and …
  • … pain
  • …

Signs will be…

  • Facial …
  • Hyper…
  • Smell of … on breath and …
A

If the cause is acidosis, symptoms will be…

  • Nausea and vomiting
  • Abdominal pain
  • Breathlessness

Signs will be…

  • Facial flush
  • Hyperventilation
  • Smell of ketones on breath and ketonuria
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11
Q

Diabetic Ketoacidosis - Clinical Features

  • Fill in the table
A
  • Age - Mostly young T1DM
  • Precipating causes - Relative or absolute insulin deficiency
  • Serum sodium- Normal or low
  • Blood Glucose - Usually <40mmol/l
  • Serum bicarbonate/pH - <14mmol/l pH<7.3
  • Serum ketones - ++++
  • Mortality - 5% depending on age
  • Subsequent course - Insulin dependent
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12
Q

Acute Complications of Diabetes - Case Study

  • What examinations & investigations?
A
  • Examination & Investigations
    • Drowsy, flushed, smelling of ketones, hyperventilating (Kussmaul respiration), still vomiting, vague abdominal pain, succussion splash
    • Blood sugar (29mmol/l)
    • Urine ketones (++++)
    • pH (6.94 - acidodic), pCO2 (4.5 - normal), HCO3 (4 - very low), Lactate (4.1)
    • Plasma hydroxybutyrate (7.5 - high (above 3 consistent with DKA))
    • Na (144), K (3.1 - low), Urea (5.8), Creat (78), eGFR (>60)
    • Hb (138g/l), Wbc (18.9)
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13
Q

Diabetic Ketoacidosis - Management

  • Correct the … derangement
  • Treat 4 things - what are they?
A
  • Correct the metabolic derangement
  • Fix the hyperglycemia, dehydration, acidosis, electrolyte losses (K+)
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14
Q

Diabetic Ketoacidosis - Management - 5 Step Plan:

  • Confirm diagnosis and check for … causes
  • … & monitor fluid balance
    • Iv fluids - saline with added …
    • Consider urinary …
  • Lower glucose
    • Intravenous insulin – fixed rate …Unit/kg/hr
  • Monitor …
    • Potassium (and sodium)
  • Prevent clots
    • Prophylactic low molecular weight …
A
  • Confirm diagnosis and check for precipitating causes
  • Rehydrate & monitor fluid balance
    • Iv fluids - saline with added potassium
    • Consider urinary catheter
  • Lower glucose
    • Intravenous insulin – fixed rate 0.1Unit/kg/hr
  • Monitor electrolytes
    • Potassium (and sodium)
  • Prevent clots
    • Prophylactic low molecular weight heparin
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15
Q

Diabetic Ketoacidosis - Other management factors

  • Is the patient …?
    • Assess G…
    • If concern, call …
  • At risk of …
    • Consider … tube
  • Monitor recovery
    • Glucose, ketones, pH, potassium - how often?
A
  • Is the patient conscious?
  • Assess GCS
  • If concern, call ITU
  • At risk of aspiration
  • Consider NG tube
  • Monitor recovery
  • Glucose, ketones, pH, potassium - hourly
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16
Q

Diabetic ketoacidosis - Recovery

  • … normal, ketones …2+ (urine), … settled
  • Resume normal …
  • Switch from intravenous to normal … insulin
A
  • pH normal, ketones <2+ (urine), vomiting settled
  • Resume normal diet
  • Switch from intravenous to normal subcutaneous insulin
17
Q

Hyperosmolar Hyperglycaemic State (HHS) - Clinical features

  • Fill in the table
A
  • 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
18
Q

Is this representing DKA or HHS?

A

HHS

19
Q

HHS - Case study

  • 78y old woman previously well. Two months polyuria & polydipsia, tiredness.
  • Had been drinking Lucozade to feel better. Had noted urine offensive to smell for several days and was experiencing dysuria.
  • Found collapsed by daughter in afternoon. Brought by ambulance to A&E.
    • What examination and investigations?
A
  • Drowsy, pale, pyrexial 38.5C, BP 80/55
  • Blood Sugar 57mmol/l - high
  • Urine ketones 0, +++ wbc, ++ nitrites, protein +++, blood +++
  • pH 7.44, pCO2 5.8, HC03 23, Lactate 1.4
  • Plasma hydroxybutyrate 0.5
  • Na144, K3.8, Urea35.2, Creat 160,
  • Hb 14.8g/dl, wbc 18.9
  • CXR – normal ECG normal
  • Osmolality: (144+3.8) x2 +35.2 +57 = 387.6 (normal 280-300mosm/kg) ​
20
Q

Calculating Osmolality:

  • Add … and … together ions, times by …, add … and blood … levels after.
  • Anything above 320 = consistent with …
A
  • Add sodium and potassium together, times by 2, add urea and blood sugar levels after.
  • Anything above 320 = consistent with HSS
21
Q

HSS - Management

  • Correct the prefound …
  • Confirm diagnosis and check for precipitating causes
  • Rehydrate & monitor fluid balance
    • Iv fluids - … with added potassium
    • Consider urinary …
  • Lower glucose (once glucose not improving with fluids)
    • Intravenous insulin – fixed rate … Unit/kg/hr
  • Monitor …
    • Potassium (and sodium)
  • Prevent …
    • Treatment low molecular weight heparin
  • Patients are often … and … ill.
A
  • Correct the prefound dehydration
  • Confirm diagnosis and check for precipitating causes
  • 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.
22
Q

Hypoglycaemia

  • Causes:
    • Too … food or … a meal; too much … or diabetes pills; more … than usual
  • Onset:
    • Often …; may pass out if untreated
A
  • Causes:
    • Too little food or skip a meal; too much insulin or diabetes pills; more active than usual
  • Onset:
    • Often sudden; may pass out if untreated
23
Q
A
24
Q

Hypoglycaemia - Definition and Classification

  • Hypoglycaemia is a biochemical term and exists when blood sugar < …mmol/l but is often used to describe a … state. The clinical syndrome associated with hypoglycaemia develops as the nervous system becomes glucose deficient or ‘…’. It can be classified:
  • Asymptomatic
    • Whilst …
    • Whilst …
  • Mild symptomatic (patient can treat …)
  • Severe symptomatic (help needed by …)
  • Coma and …
A
  • 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:
  • Asymptomatic
    • Whilst Awake
    • Whilst sleeping
  • Mild symptomatic (patient can treat himself)
  • Severe symptomatic (help needed by third party)
  • Coma and convulsions
25
Q

Hypoglycaemia - Symptoms

  • … symptoms – … activation
    • Sweating, feeling hot
    • Trembling or shakiness
    • Anxiety
    • Palpitations
  • … symptoms
    • Dizziness, light-headedness
    • Tiredness
    • Hunger, nausea
    • Headache
    • Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism
    • Coma and convulsions, hemiplegia
A
  • 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
26
Q

Hypoglycaemia - Symptoms

  • Autonomic symptoms – sympathomedullary activation
    • What are the 4 symptoms?
  • Neuroglycopenic symptoms
    • What are the 6 symptoms?
A
  • Autonomic symptoms – sympathomedullary activation
    • Sweating, feeling hot
    • Trembling or shakiness
    • Anxiety
    • Palpitations
  • Neuroglycopenic symptoms
    • Dizziness, light-headedness
    • Tiredness
    • Hunger, nausea
    • Headache
    • Inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism
    • Coma and convulsions, hemiplegia
27
Q

Hypoglycaemia - Causes

  • Insulin
    • Inappropriately … doses
    • Not eating, or insufficient …
  • S… (med for type 2 diabetes)
A
  • Insulin
    • Inappropriately excessive doses
    • Not eating, or insufficient carbohydrate
  • Sulfonylureas
28
Q

Hypoglycaemia - counter-regulation

  • Glucagon, adrenaline, cortisol and GH all have ‘anti-… effects’
    • Glucagon stimulates glycogenolysis and gluconeogenesis and is probably … response
    • Adrenaline increases gl…
    • GH and cortisol limit glucose … in peripheral tissues, but this effect takes … so of little benefit acutely
  • … nerves may also directly activate hepatic glycogenolysis and stimulate … secretion
A
  • 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
29
Q

Hypoglycaemia - Treatment

  • Minor episodes
    • …g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something ‘…’ to eat
    • Glucose …
  • Hypoglycaemic …
    • im or iv Glucagon 1mg
    • iv … 25g (150ml 10% glucose)
A
  • 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)
30
Q

Diabetic Emergencies - Summary

  • DKA
    • Insulin … > k… > ac…
    • Treat with …, fluids and …
  • HSS
    • Relative insulin deficiency > …glycaemia > profound …
    • Treat with fluids & insulin
  • Hypo
    • Too much …
    • Treat with …
A
  • DKA
    • Insulin deficiency > ketosis > acidosis
    • Treat with insulin, fluids and potassium
  • HSS
    • Relative insulin deficiency > hyperglycaemia > profound dehydration
    • Treat with fluids… insulin
  • Hypo
    • Too much insulin
    • Treat with glucose

Year 2 Medicine (162 decks)

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