Hypoglycaemia, DKA Flashcards
(17 cards)
Adults with symptoms of hypoglycaemia with blood glucose >4mmol/L
Treat with small carbohydrate snack (eg.slice of bread or a normal meal if due)
Adults with hypoglycaemia with blood glucose<4mmol/l with or without symptoms
- if patient is conscious and able to swallow treat with fast acting carb by mouth. Eg, Lift glucose liquid, glucose tablets, glucose 40% gels (eg.glucogel,dextrose or rapilose) - pure fruit and sugar (sucrose) dissolved in appropriate volume of water. Oral glucose formulations are proffered as absorption occurs more quickly
- dissolved sugar sucrose (not suitable for patients taking Acarbose) this prevents the breakdown of sucrose to glucose
- avoid orange juice (high in potassium) in patients that are following a low potassium diet due to ckd disease
- avoid chocolate and biscuits(have a lower sugar content and high fat content - which may delay gastric emptying) - food moving from stomach to duodenum
Duration of treatment and extended hypoglycaemia
If necessary repeat treatment after 15 mins up to a max of 3 treatments in total
Once blood-glucose conc is above 4 mmol/l and patient has recovered a snack containing a long acting carb should be given (eg.two biscuits, one slice of bread, 200-300ml of milk)
- do not omit insulin if due, but dose regimen may need to be reviewed
- if hypoglycaemia is unresponsive (blood glucose remains<mmol/l after 30-45 mins or after 3 treatment cycles) treat with IM glucagon or glucose 20% intravenous infusion
- alcoholic patients , give thiamine with or following admin of IV glucose to reduce risk of wernicke’s encephalopathy
Avoid glucagon in the following
Glucagon mobilises glycogen in the liver so its ineffective in patients whose liver glycogen is depleted eg.
Prolonged fasting
Adrenal insufficiency
Chronic hypoglycaemia
Alcohol induced hypoglycaemia
In patients taking sulfonylureas give IV glucose instead
Diabetic complications - Diabetes and cardiovascular disease
- Diabetes is a strong risk factor for CVD
- Aldo address other risk factors (smoking,hypertension,obesity and hyperlipidaemia
- CV risk in diabetic patients further reduced with ACEi, low dose aspirin and lipid regulating drugs)
Diabetic nephropathy
BP should be reduced to lowest level to prevent decline of glomerular filtration rate and reduce proteinuria
Test for urinary and serum creatinine levels
If tests negative, test urine for microalbuminuria (earliest sign of nephropathy) all patients with nephropathy should be given ACEi or Arb if not contraindicated even if BP is normal
ACEi should also be given if patients with CKD and proteinuria to reduce progressions of CKD
Pain killers use for diabetic neuropathy
-Paracetamol or NSAIDS
-Duloxetine,venlafaxine can be used for pain and amitriptyline and imipramine are alternatives (unlicensed)
-pregabalin and Gabapentin can also be tried if all the above are not effective
- opioid analgesics in combination with pregabalin(Tramadol,morphine,oxycodone)
- autonomic neuropathy - use tetracyclines and erythromycin (unlicensed),codeine
Signs of DKA
-dehydration due to polydipsia and polyuria
- weightloss
-excessive tiredness
-Nausea and vomitting
- Abdominal pain
- Rapid and deep respiration
-sweet smell to breath (acetone breath)
- reduced consciousness
- sweet or metallic task in mouth
- different odour to urine/sweat
Signs and symptoms of hyperglycaemic state
- Dehydration sue to polydipsia and polyuria
- weightloss
- weakness
- Tachycardia
- Hypotension
- Poor skin Turgor
- Acute congnitive impairment
- Shock in severe cases
Diabetic hyper glycemic emergencies summaries
Check the table princessssss
Diabetic ketoacidosis - management
- management involves (fluid +electrolyte+insulin)
- Give sodium/potassium chloride - 0.9% IV infusion if systolic BP < 90 mmHg for 10-15 mins. Repeat if BP remains low and seek medical advice
- Mix sodium chloride 0.9% with soluable insulin in an infusion to a concentration of 1 unit /ml - infuse at a fixed rate of 0.1 units/kg/hr
- monitor blood glucose and blood ketones hourly
- continue long acting insulin analogues (determine and glargine) during the treatment of DKA
Diabetes, surgery and medical illnesses
- all patients should have emergency treatment for hypoglycaemia written on their drug chart on admission
- use of insulin during surgery: adjust doses based on the patient
- on the day before the surgery, insulin should be given as normal, except long acting once daily insulins, these should be given at a reduced dose. The dose should be reduced by 20%
- on the day of the surgery, stop all other insulins nad continue 80% long acting until the patient is eating and drinking again after surgery
Reducing doses day before surgery
For long acting insulin = OD ( reduce the dose by 80%)
All other insulins = give as normal
Variable rate insulin (soluable) infusion - give IV KCL + glucose and sodium
Day of surgery and throughout surgery
Long acting insulin = 80%
All other insulins = stop (until eating and drinking again)
Variable rate insulin (soluable infusion)
IVKCL and glucose + sodium = give glucose and insulin infusion (until 30-60 mins after 1st meal)
Diabetic drugs during surgery -STOP ONCE INSULIN INFUSION COMMENCE
Acarbose
Sulfonylureas
Pioglitazone
Meglitinides
SGLT2i
Gliptins
Continue once insulin infusion is commenced - during surgery
Metformin
GLP-1 agonists
Anti-diabetic drugs and surgery
- insulin is almost always required in medical and surgical emergencies
- most anti diabetic oral medication should be stopped and insulin infusion is commenced and not restarted until the patient is eating and drinking normal
- manufacturers of some anti diabetic drugs recommended that they may need to be replaced temporarily with insulin during intercurrent illness when the drug is unlikely to contro lhyperglycaemias (eg.severe infection,trauma,coma,Mi,medical emergencies)
