Hypo/Hyperglycaemia

Question 1

when non-diabetics start developing symptoms of hypoglycaemia vs diabetics

Answer 1

<3.6mmol/L vs <3.9mmol/L

Question 2

Non-diabetic hypoglycaemia vs diabetic

Answer 2

Whipple’s Triad
1) signs and symptoms
2) low serum glucose
3) resolution after given glucose

Diabetics will have a low serum glucose but not necessarily have symptoms

Question 3

most common causes of hypoglycaemia in diabetics

Answer 3

• fasting
• increased exercise / glucose utilisation
• higher than normal insulin doses
• sulphonylureas
• alcohol / decreased endogenous production
• higher insulin sensitivity with weight loss and exercise
• reduced renal clearance = renal failure

Question 4

causes of hypoglycaemia in non-diabetics

Answer 4

Alcohol abuse in combo with malnourishment
Acute liver failure
Sepsis and malaria
Drugs - B blocker, valproate, salicylate overdose
Addisons, adrenal crisis
Myxoedema
Starvation
Tumours e.g. insulinoma

Question 5

what is activated in the presence of hypoglycaemia?

Answer 5

sympathetic overactivity
- palpitations
- blurred vision
- cant concentrate
- sweating
- shaking
- confusion
- tingling in the mouth

Question 6

what can blunt sympathetic response

Answer 6

B-blockers

Question 7

what happens in well controlled diabetics

Answer 7

they have more frequent episodes, and desensitised to the response

Question 8

what happens if glucose drops below 2.6mmol/L

Answer 8

confusion
convulsion
CVA-like symptoms
coma

= neuroglycopenia

Question 9

what investigations should be done in a case of hypoglycaemia?

Answer 9

• fingerprick and lab glucose
• U/E
• take bloods in non-diabetic patients if possible for insulin and C-peptide levels

Question 10

Low C-peptide and high insulin level

Answer 10

exogenous insulin

Question 11

high C-peptide and insulin

Answer 11

endogenous insulin

Question 12

mx of hypoglycaemia

Answer 12

1. replace glucose
2. repeat prick in 10 mins

** permanent damage can occur of left for 4 hours **

Question 13

immediate action for hypoglycaemia

Answer 13

1. Non-drug rx
   - ABCs
   - take blood glucose
   - gain IV access
2. Drug rx
   - in alcoholics and malnourished = Thiamine 1-2mg/kg to avoid Wernicke’s

• if awake: 50g dextrose or PO sugar water
• if unconscious: 50ml 50% dextrose IV
• if no IV access: 1mg Glucagon IM –> 50% dextrose PO when awake

Question 14

what should be done if hypoglycaemia is not related to drugs and no cause is found?

Answer 14

5% Dextrose infusion of 50-100ml/hr
+ take glucose every 2 hours

> refer

Question 15

what should be done in hypoglycaemia if related to drugs, overdose or alcohol?

Answer 15

1. eat
2. 2 hrly glucose
3. increase IV conc
4. find co-causes
5. adjust diabetic meds
6. refer

Question 16

referral criteria for hypoglycaemics

Answer 16

if not a diabetic with a clear reversible cause

Question 17

3 discharge criteria for hypoglycaemia

Answer 17

1) asymptomatic 6 hours post-infusions
2) cause found and corrected
3) follow-up arranged

Question 18

DKA

Answer 18

It occurs when the body produces high levels of blood ketones in response to its inability to produce or use insulin.

Question 19

HHS

Answer 19

Hyperosmolar hyperglycaemic state (HHS) complicates mainly type II diabetes. A very high blood glucose level causes severe dehydration and elevated blood osmolality.

Question 20

DKA pathophysiology

Answer 20

is caused by absolute or relative decrease in insulin levels.
Plasma glucose increase causes an osmotic diuresis, with Na + and water loss (up to 8–10L),

hypotension, hypoperfusion, and shock

Normal compensatory hormonal mechanisms are overwhelmed and lead to an increase in lipolysis.
In the absence of insulin this results in the production of non-esterified fatty acids, which are oxidized in the liver to ketones.
Younger undiagnosed diabetics often present with DKA developing over 1–3 days. Plasma glucose levels may not be grossly increased; euglycaemic ketoacidosis can occur.

Question 21

causes of HHS

Answer 21

It is caused by intercurrent illness, inadequate diabetic therapy and dehydration.

Question 22

character of HHS

Answer 22

It develops over days/weeks, and is more common in the elderly.
HHS is characterized by an increase in glucose levels (> 30mmol/L), increased blood osmolality, and a lack of urinary ketones.

Question 23

presentation of hyperglycaemic state?

Answer 23

1 - dehydration
2 - GI symptoms
3 - hyperventilation
4 - altered mental status
5 - generalised fatigue, malaise and weakness

Question 24

signs of dehydration

Answer 24

thirst, polydipsia, polyuria, decreased skin turgor, dry mouth, hypotension, tachycardia.

Question 25

signs of GI symptoms in hyperglycaemia

Answer 25

nausea, vomiting, and abdominal pain. This can be severe and mimic an ‘acute surgical abdomen’.

Question 26

DKA compensation

Answer 26

(respiratory compensation for the metabolic acidosis) with deep rapid breathing (Kussmaul respiration) and the smell of acetone on the breath, is pathognomonic of DKA.

Question 27

common underlying conditions in hyperglycaemic crisis

Answer 27

Sepsis Acute Coronary Syndrome CVA Pancreatitis New DM Infection: common primary foci are urinary tract, respiratory tract, skin. Infarction: myocardial, stroke, GI tract, peripheral vasculature. Insufficient insulin. Intercurrent illness: many underlying conditions precipitate or aggravate DKA and HHS, as mentioned above.

Question 28

Ddx for hyperglycaemia

Answer 28

Acute Pancreatitis Alcoholic Ketoacidosis Appendicitis Cystitis in Females Hyperosmolar Coma Hypophosphatemia Hypothermia Lactic Acidosis Metabolic Acidosis Salicylate Toxicity Septic Shock

Question 29

immediate management in hyperglycaemic crisis

Answer 29

Stabilise patient using the ABCs approach If altered consciousness/coma is present, provide and maintain a patent airway. Assess breathing and circulation. High flow O2 if hypoxic. Assess blood pressure and circulation. Establish IV access. Immediate fluid bolus if circulation impaired (use crystalloid); Assess level of consciousness, check glucose stat and 2 hourly. Expose patient enough to be able to do a thorough assessment, but minimize heat loss.

Question 30

fluid mx for hyperglycaemia

Answer 30

Fluid boluses of 0.9% Saline (20-30ml/kg) till systolic blood pressure above 90. Then: 1L IV 0.9% Saline over 1 Hour 1L IV 0.9% Saline over 2 Hours 1L IV 0.9% Saline over 4 Hours 1L IV 0.9% Saline 6 Hourly If glucose drops below 15mmol/L change to 1L 5% Dextrose containing fluid (Rehydration Solution) 6 Hourly If HHS: Consider changing to 0.45% Saline if glucose and osmolality not declining despite usual regime above. Careful: Elderly patients and patients with poor cardiac function need very careful monitoring and observation with the fluid regime above and the rate of administration might need to be adjusted.

Question 31

insulin rx in hyperglycaemic state

Answer 31

Only start once - Patients is resuscitated to a systolic blood pressure of at least 90. - Potassium level is known and relative or absolute potassium deficit is being addressed with potassium replacement Start an infusion of soluble insulin using an IV pump or paediatric burette at 6U/hr (50 units Actrapid in 200ml 0.9% Saline, run at 24ml/hour). No loading dose is required. If no rate minder is available 10 units Actrapid subcutaneously stat, then 6 units subcutaneously hourly Check plasma glucose levels every hour initially. Keep infusion rate constant, but change to 5% Glucose containing solution once glucose level falls below 15mmol/L.

Question 32

what electrolytes should be checked in high glucose states?

Answer 32

* potassium is most important Other: Ca, Mg, Ph With treatment, K + enters cells and plasma levels decrease: therefore, unless initial K + levels are > 5mmol/L, give K+ 20mmol in each litre of fluid if K+ 4.1 – 5 mmol/L 30mmol in each litre of fluid if K+ = 3.1 – 4 mmol/L 40mmol in each litre of fluid if K+ < 3.1 mmol/L

Question 33

should bicarb be given in DKA?

Answer 33

Bicarbonate administration has not been shown to improve mortality or morbidity. Has been shown to worsen the ketosis and delays ketone clearance. Only consider if patient has been fully resuscitated to a systolic blood pressure above 90mmHg and the pH is below 7. --> Consider an NG tube to decrease risk of gastric dilation and aspiration.

Question 34

what adjunctive therapies can be given to high glucose ?

Answer 34

maybe broad spectrum Ab if no response and pH is below 7 Monitor urine output (most accurate with urinary catheter). If patient is drowsy/decreased level of consciousness give DVT prophylaxis. Arrange admission to ICU, HDU, or acute medical admissions unit.

Question 35

DKA resolution parameters

Answer 35

*GBPACE* Glucose < 11mmol/L Bicarbonate >/= to 18 pH > 7.3 Anion gap < 12 Normal level of consciousness Patient able to eat and drink

Question 36

extra investigation for DKA

Answer 36

Aim to confirm the diagnosis and search for possible underlying cause(s): Check blood glucose and ketone levels and test the urine for glucose and ketones. Send blood for U&E, blood glucose, creatinine, osmolality (or calculate it): mOsm/L= (2 × Na + ) + glucose (mmol/L) + urea (mmol/L). Check Venous Blood Gas (look for metabolic acidosis ± respiratory compensation). FBC CXR (to search for pneumonia). ECG and cardiac monitoring (look for evidence of hyper/hypokalaemia). If infection/sepsis suspected, as appropriate: Blood cultures Throat or wound swabs Urine/sputum microscopy and culture.

Question 37

dka discharge criteria

Answer 37

Emergency Centre if DKA or HHS is confirmed, admit as above. -Simple hyperglycaemia with identified cause with expected uncomplicated course could be considered for discharge. -When discharged from the medical ward the patient must be supplied with a follow-up date at MOPD as well as a referral letter to the clinic detailing interim management.