Acute Complications of Diabetes

Question 1

What is Diabetic keto-acidosis? (DKA)

Answer 1

• 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

Question 2

DKA is more common in which type of diabetes?

Answer 2

Type 1

Question 3

What is Hyperosmolar hyperglycaemic state? (HHS)

Answer 3

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

Question 4

Which is rarer, DKA or HHS?

Answer 4

HHS

Question 5

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?..)

Answer 5

• 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)

Question 6

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 …
• …

Answer 6

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

Question 7

Diabetic Ketoacidosis - Clinical Features

• Age - Mostly … with Type … DM
• Precipitating causes - Relative or absolute … deficiency

Answer 7

• Age - Mostly young T1DM
• Precipitating causes - Relative or absolute insulin deficiency

Question 8

Diabetic ketoacidosis - Precipitating factors

• Infections - such as … (3)
• Error/ missed … administration
• Myocardial infarction
• Previously undiagnosed …
• Drugs: such as …
• Unidentified

Answer 8

• Infections - pneumonia, urinary tract, viral gastroenteritis
• Error/ missed insulin administration
• Myocardial infarction
• Previously undiagnosed Type 1 diabetes
• Drugs: Steroid
• Unidentified

Question 9

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 & …

Answer 9

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

Question 10

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 …

Answer 10

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

Question 11

Diabetic Ketoacidosis - Clinical Features

• Fill in the table

Answer 11

• 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

Question 12

Acute Complications of Diabetes - Case Study

• What examinations & investigations?

Answer 12

• 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)

Question 13

Diabetic Ketoacidosis - Management

• Correct the … derangement
• Treat 4 things - what are they?

Answer 13

• Correct the metabolic derangement
• Fix the hyperglycemia, dehydration, acidosis, electrolyte losses (K+)

Question 14

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 …

Answer 14

• 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

Question 15

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?

Answer 15

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

Question 16

Diabetic ketoacidosis - Recovery

• … normal, ketones …2+ (urine), … settled
• Resume normal …
• Switch from intravenous to normal … insulin

Answer 16

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

Question 17

Hyperosmolar Hyperglycaemic State (HHS) - Clinical features

• Fill in the table

Answer 17

• 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

Question 18

Is this representing DKA or HHS?

Answer 18

HHS

Question 19

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?

Answer 19

• 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) ​

Question 20

Calculating Osmolality:

• Add … and … together ions, times by …, add … and blood … levels after.
• Anything above 320 = consistent with …

Answer 20

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

Question 21

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.

Answer 21

• 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.

Question 22

Hypoglycaemia

• Causes:
  
  • Too … food or … a meal; too much … or diabetes pills; more … than usual
• Onset:
  
  • Often …; may pass out if untreated

Answer 22

• 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

Question 24

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 …

Answer 24

• 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

Question 25

_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

Answer 25

* **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

Question 26

_Hypoglycaemia - Symptoms_ * **Autonomic** symptoms – **sympathomedullary** activation * What are the 4 symptoms? * **Neuroglycopenic** symptoms * What are the 6 symptoms?

Answer 26

* **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*

Question 27

_Hypoglycaemia - Causes_ * Insulin * Inappropriately ... doses * Not eating, or insufficient ... * S... (med for type 2 diabetes)

Answer 27

* Insulin * Inappropriately **excessive** doses * Not eating, or insufficient **carbohydrate** * **Sulfonylureas**

Question 28

_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

Answer 28

* 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

Question 29

_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)

Answer 29

* Minor episodes * **20**g 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)

Question 30

_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 ...

Answer 30

* 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**