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Flashcards in Diabetic Emergencies Deck (46)
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1
Q

What is diabetic ketoacidosis (DKA)?

A

Disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in counter regulatory hormones

2
Q

Who gets DKA?

A

Can occur in both type 1 and 2 diabetics, but more common in type 1

3
Q

What causes ketoacidosis?

A

Increased lipolysis causes increased FFA to the liver, increases ketogenesis which causes acidosis
Glycosuria leads to electrolyte loss and dehydration, causing increased lactate and acidosis

4
Q

What is needed for biochemical diagnosis of DKA?

A

Ketonaemia > 3mmol/L or significant ketonuria (>2++ on standard urine stick)
Blood glucose > 11.1 mol/L or known DM
Bicarbonate < 15 morning/L or venous pH < 7.3

5
Q

What is the mortality rate in DKA?

A

2-5% in developed countries

6-24% in developing countries

6
Q

What causes death from DKA?

A
Adults = hypokalaemia, aspiration pneumonia, ARDS, co morbidities 
Children = cerebral oedema
7
Q

What are some precipitants to DKA?

A

Newly diagnosed, infection, illicit drug and alcohol use, non-adherence to insulin/poor self management (most common cause)

8
Q

What are osmotic symptoms of DKA?

A

Thirst and polyuria

9
Q

What are ketone body related symptoms of DKA?

A

Flushing, vomiting, abdominal pain and tenderness, breathless (Kussmaul’s respiration), smell of ketones on breath

10
Q

What are some conditions associated with DKA?

A

Underlying sepsis, gastroenteritis, coma (rare), thrombo-embolism

11
Q

What are the typical biochemistry results at diagnosis of DKA?

A

Glucose = median level 40 mmol/L, from 11- >100
Potassium = often raises above 5.5 mmol/L
Creating often raised, sodium low, raised lactate, amylase raised, median white cell count is 25
Ketones > 5, bicarbonate < 10 in severe cases

12
Q

What can be lost in DKA?

A
Fluid = up to 12L
Sodium = 500 mmol
Potassium = 350-700 mmol
Phosphate = 50-100 mmol
13
Q

What are some complications of DKA?

A

Cardiac arrest secondary to hypokalaemia, ARDS, cerebral oedema, gastric dilation (risk of aspiration)

14
Q

Where are patients with DKA managed?

A

In HDU

15
Q

How are fluids managed in patients with DKA?

A

Initially with 0.9% NaCl, once glucose falls to 15 switch to dextrose

16
Q

What are some other management requirements for patients with DKA?

A

Replace insulin and potassium (rarely phosphate and bicarbonate), possible nasogastric tube, monitor potassium, prescribe prophylactic LMWH

17
Q

How are blood ketones measured?

A

Using optium meter = measures beta hydroxybutyrate, meter range is 0-8mmol/L, <0.6 mmol/L is normal

18
Q

How are urine ketones measured?

A

Measure acetoacetate, indicates levels of ketones 2-4hrs previously

19
Q

Does ketonuria resolve straight away in DKA?

A

No = persists after clinical improvement

20
Q

How can recurrence of DKA be prevented?

A

Provide patient with ketone meter, arrange DSN follow up and inform GP

21
Q

How is hyperglycaemic hyperosmolar syndrome (HHS) diagnosed by biochemistry l?

A

Hypovolaemia, hyperglycaemia > 30mmol/L, no/mild ketonaemia < 3mmol/L, bicarbonate > 15mmol/L, venous pH >7.3, osmolarity >320mosmol/kg

22
Q

What can HHS overlap with to cause a mixed clinical picture?

A

DKA

23
Q

What is the typical presentation of HHS?

A

Diabetes may be known at presentation (often not), older patients or young Afro Caribbean’s, high refined CHO intake pre-presentation

24
Q

What are some complications and associations of HHS?

A

MI, stroke, sepsis

Associated medication = steroids, thiazide diuretics

25
Q

Wha is the typical biochemistry of HHS?

A

Higher glucose than DKA = usually above 50mmol/L, significant renal impairment, sodium often raised, less ketogenic/acidotic than DOA, raised osmolarity

26
Q

How is osmolarity calculated l?

A

2[Na] + urea + glucose

Normal is 275-295

27
Q

How should HHS be treated?

A

Administer fluids more cautiously (risk of increased overload)
Administer insulin slowly or not at all
Sodium = <0.5mmol/L/hr, may need 0.45% saline

28
Q

Why should HHS patients be screened for comorbidities?

A

More likely for comorbidities to occur = all patients get LMWH unless contraindicated

29
Q

What are some features of alcoholic/starvation ketoacidosis?

A

History important, dehydration common and marked, ketonuria >3mmol/L or significant ketonuria (>2+), bicarbonate usually <15mmol/L or venous pH <7.3 in severe cases, glucose usually normal

30
Q

What are some features of in-patient experience of diabetics?

A

Longer stay, higher in-patient mortality, higher risk of medical error, enhanced foot risk, poorer overall experience

31
Q

What are some reasons that type 1 diabetics are admitted to hospital?

A

Unable tolerate oral fluids, persistent vomiting, persistent hyperglycaemia, abdominal pain/SOB, persistent positive/increasing levels of ketones

32
Q

What is the target in-patient blood sugar?

A

6-10mmol/L, range of 4-12mmol/L is acceptable

33
Q

What patients don’t require right control of their blood sugar?

A

End of life patients, those who may be severely disabled by significant hypoglycaemia

34
Q

What are some features of elective surgical procedures?

A

Planned, preferably first on list, pre-assessment clinics

Anaesthetic risk = CV, autonomic dysfunction, foot risk, HbA1c at least <70m/m

35
Q

What are some features of emergency surgery?

A

Increased risk as unplanned, anaesthetic risk in those with micro/macro vascular complications, care with potassium if glucose is high, post operative sepsis and foot care risks

36
Q

Where does lactate originate from?

A

Red cells, skeletal muscle, brain and renal medulla = end product of anaerobic metabolism of glucose

37
Q

What is required for lactate clearance?

A

Hepatic uptake and aerobic conversion to pyruvate then glucose

38
Q

What can lactic acidosis be confused with?

A

Hyperlactaemia

39
Q

What is the normal lactate range?

A

0.6-1.2mmol/L = generally lowest in fasted state, may rise to 10mmol/L in severe exercise

40
Q

How is the ion gal calculated?

A

[Na + K] - [HCO3 + Cl]

Normal range is 10-18 mmol/L, useful for determining cause of acidosis

41
Q

What is type A lactic acidosis?

A

Associated with tissue hypoxaemia = infarcted tissue, cardiogenic/hypovolaemic shock, sepsis, haemorrhage

42
Q

What are some features of type B lactic acidosis?

A

May occur in liver disease or leukaemic states, associated with diabetes, consider rare inherited metabolic conditions if well and non-diabetic

43
Q

How does type B lactic acidosis occur in diabetics?

A

10% of DKA associated with lactate > 5mmol/L, associated with metformin in severe illness states or renslnfailure

44
Q

What are the clinical signs of lactic acidosis?

A

Hyperventilation, mental confusion, stupid or coma if severe

45
Q

What are the lab findings for lactic acidosis?

A

Reduced bicarbonate, raised anion gap, raised phosphate, absence of ketonaemia, glucose variable (often raised)

46
Q

How is lactic acidosis treated?

A

Treat underlying condition with fluids and antibiotics l, and withdraw offending medication