Acute complications of diabetes

Question 1

What is the pathophysiology of diabetic ketoacidosis?

Answer 1

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 2

How is diabetic ketoacidosis managed?

Answer 2

5 Step Plan:
Confirm diagnosis and check for precipitating causes.
Rehydrate and monitor fluid balance: IV fluids - saline with added potassium, consider urinary catheter.
Lower glucose: intravenous insulin.
Monitor electrolytes - potassium (and sodium)
Prevent clots - prophylactic low molecular weight heparin

Question 3

What can ketoacidosis lead to?

Answer 3

Electrolyte disturbances – renal losses
Potassium depletion
Sodium depletion - dehydration

Question 4

What are the precipitating factors of ketoacidosis?

Answer 4

Infections – pneumonia, urinary tract, viral illnesses, gastroenteritis
Missed insulin administration
Myocardial infarction
Previously undiagnosed type 1 diabetes
Drugs: steroids
Unidentified

Question 5

What are the symptoms, causes and signs of ketoacidosis?

Answer 5

Symptoms: thirst and polyuria. weakness and malaise, drowsiness, confusion.
Cause: hyperglycaemia + dehydration
Signs: dry mouth, sunken eyes, postural hypotension,
hypothermia and coma.
Symptoms: nausea and vomiting, abdominal pain.
breathlessness.
Cause: acidosis.
Signs: facial flush, hyperventilation, smell of ketones on breath and ketonuria.

Question 6

What are the clinical features of ketoacidosis in terms of age, precipitating causes, serum sodium, serum pH, serum ketones, mortality and subsequent course?

Answer 6

Age: mostly young T1DM
Precipitating causes: relative or absolute insulin deficiency
Serum sodium: normal or low
Serum ketones: high
Serum pH: pH<7.3
Mortality: 5% depending on age
Subsequent course: insulin dependent

Question 7

What are the clinical features of hyperosmolar hyperglycaemic state in terms of age, precipitating causes, serum sodium, serum pH, serum ketones, mortality and subsequent course?

Answer 7

Age: usually >40years
Precipitating causes: previously undiagnosed, steroids, diuretics, sugar.
Serum sodium: usually high.
Serum pH: normal
Serum ketones: 0
Mortality: 30% (thromboses)
Subsequent course: diet/tablet controlled

Question 8

How is hyperosmolar hyperglycaemic state managed?

Answer 8

Correct the profound dehydration (similar to ketoacidosis)

Question 9

What are the classifications of hypoglycaemia?

Answer 9

Asymptomatic: awake, sleeping.
Mild symptomatic (patient can treat himself).
Severe symptomatic (help needed by third party).
Coma and convulsions.

Question 10

What are the autonomic symptoms of hypoglycaemia?

Answer 10

sympathomedullary activation: sweating, feeling hot,

trembling or shakiness, anxiety, palpitations

Question 11

What are the neuroglycopenic symptoms of hypoglycaemia?

Answer 11

Dizziness, light-headedness, tiredness, hunger, nausea
headache. inability to concentrate, confusion, difficulty speaking, poor coordination, behavioural change, automatism. coma and convulsions, hemiplegia.

Question 12

What are the causes of hypoglycaemia?

Answer 12

Insulin - inappropriately excessive doses, not eating or insufficient carbohydrate.
Sulfonylureas.

Question 13

Which molecules have anti-insulin effects?

Answer 13

Glucagon, adrenaline, cortisol and GH

Question 14

What is the treatment for minor hypoglycaemic episodes?

Answer 14

20g carbohydrate as sugary drink, fruit juice, glucose tablets, glucose gels followed by something ‘starchy’ to eat. Glucose gels.

Question 15

What is the treatment for hypoglycaemic coma?

Answer 15

IM or IV glucagon 1mg

IV dextrose 25g (150ml 10% glucose)