Diabetic Emergencies

Emergency Block

DKADKA PATHOPHYSIOLOGY

• Severe insulin deficiency

• increased glucagon promotes lipolysis

• Results in a massive increase in ketogenesis

DIABETIC EMERGENCIES

• KETONES

• ACETOACETATE

• ACETONE

• β HYDROXY BUTYRATE

<1.5mmol/l

More than 3mmol/l in blood

Pathophysiology

Insulin deficiency and glucagon excess

↑ Blood ketones ↑ Blood glucose

Acidosis Osmotic diuresis

Fluid and electrolyte disturbance

Cerebral oedema Shock

Vomiting

Cellular dysfunction

Who gets DKA?

• Hallmark of type 1 diabetes

• Previously undiagnosed DM (about 25 – 30%)

• Interruption to normal insulin regime

• Intercurrent illness - usually infection

Symptoms and signs

• Nausea• Vomiting• Abdominal pain• Preceding polyuria, polydipsia, weight loss

• Drowsiness/confusion/coma• Kussmaul respiration - hyperventilation• ‘Pear drops’ breath• Sign of infection or assoc disease _ (MI,

pancreatitis)

How do I diagnose DKA?

Diagnosis requires all 3 of the following:

• Ketonaemia 3 mmol/L and over or significant ketonuria (more than 2+ on standard urine sticks)

• Blood glucose over 11 mmol/L or known diabetes mellitus

• Bicarbonate (HCO3- ) below 15 mmol/L and/or venous pH less than 7.3

Investigations

• Bloods– FBC, UE, HCO3, LFT, CRP, Glu, cultures, amylase,

cardiac enzymes, Blood ketones

• Urine– Ketones, MSU

• ABG– Initially only (lab HCO3 after)

• CXR• ECG

Example ABG

Patient 1

pH 7.35

pCO2 3.2

pO2 16.0

HCO3 16.1

Patient 2

7.1

2.1

9.1

11.2

Treatment priorities

1. Replace fluids

2. Replace electrolytes

3. Replace insulin

4. Look for cause

5. Close monitoring

Replacing fluids

Initial management

• 1L 0.9% NaCl • 30 mins• 1hr• 2hr• 4 hr

Then continue NaCl 0.9% as dictated by fluid status

Later

• Slow NaCl and run 5% dextrose concurrently when gluc <15mmol

• If gluc normal but still ketones continue steady insulin with 5% or 10% dextrose (avoids recurrent DKA)

Replace electrolytes

• K+ is most important

• Insulin shifts K+ into cells therefore K+ will fall as rehydrate

• Consider adding K+ when serum K+ < 5.5

• Hyponatraemia may occur due to osmotic effect of glucose - it will correct with treatment of DKA

Key Changes

• Fixed rate insulin infusion– 0.1 u/kg/hr– Even when near normoglycaemia attained

• Monitoring of capillary beta-hydroxybutyrate– Diagnosis– Monitoring adequacy of treatment– Endpoint for completion of treatment

Monitoring

• Monitor urine output and vital signs closely– catheterize

• Repeat U&E, glucose, venous bicarbonate – ABG PAINFUL

• 2 – 4 hours, 6 - 8 hours, 12 hours, 24 hours

• Repeat ABG at 2 hours if not improving• ? Alternative cause for acidosis e.g. lactate

What should we be expecting?• Wallace et al 2001

– Ketones on presentation 3.9 – 12.33

– Median half life of beta-hydroxybutyrate was 1.64 hrs

– Suggested rate of ketone fall of 1 mmol/l/hr as indicator of adequate treatment

The hospital and home use of a 30-second hand-held blood ketone meter: guidelines for clinical practiceT. M. Wallace, N. M. Meston*, S. G. Gardner² and D. R. MatthewsDiabetic Medicine, Volume 18, Issue 8 (p 640-645)

Suggestions

• Review if glucose not improving by 3-5 mmol/L/h or ketones by 0.5 – 1 mmol/L/h

1. First check hydration has been addressed2. Check infusion equipment

• Lines• Pump• Solution

3. Increase rate of insulin infusion• Unclear by how much• Some sources say double• Guidelines say increase by 1-2u/h

Cause of Vomiting and Abdominal Pain

• Vomiting – Excess ketone bodies causes vomiting– Gastric atony due to electrolyte imbalance

• Abdominal pain– Peritoneal dehydration– Pancreatitits

What happens to the following in DKA?Plasma Total body

Magnesium

Phosphate

Chloride

Cholesterol

Triglycerides

Lipoprotein

Amylase

With treatment

Pitfalls• Does a high wcc mean infection?

• No, not necessarily!• Give antibiotics as guided by findings

• Absence of fever doesn’t mean absence of infection

• Consider alternative cause for acidosis if glucose and acidosis markedly out of proportion

• Non specific abdo pain and raised amylase doesn’t always mean pancreatitis

• Do not stop insulin even if the blood glucose is normal or below 4

Discharge, Prognosis and Prevention

• How do you stop a sliding scale? – Overlap with normal insulin (breakfast) and keep in for

an other 24 hours to monitor BMs

• Prevention – Diabetic nurse + docs can use opportunity for patient

education about insulin regime etc.

• Mortality is < 5%– Patients with frequent episodes are at increased risk of

dying and diabetic complications

HHS/HONK

• Hallmark of type 2 DM

• May occur in:• New diagnosis

• Poor compliance with treatment

• Intercurrent illness – especially MI, Infection, CVA

• Drugs- Steroids

• Sugary drinks

glycogenolysis gluconeogenesis proteolysis lipolysis Tissue glucose uptake

Plasma amino acidsPlasma free fatty acids

ketogenesis

ketonaemia

acidosis

Urea synthesis

vomiting

hyperventilation

Renal H+ excretion GFR

hypovolaemia

Loss of water Na & K +

Plasma osmolality

thirst

Glycosuria/ Osmotic diuresis

hyperglycaemia

Hepatic glucose output

Prerenal uraemia

Why is it different from DKA?

• Insulin production markedly reduced but NOT absent.

• No switch to fat metabolism and therefore no ketones or acidosis

• Mortality markedly higher– Co-morbidities, longer time to diagnosis,

electrolyte disturbances– Cerebral oedema and Pulmonary Embolism more

common

How do I recognise it?

• Diagnosis requires ALL of the following:

• Raised blood glucose (usually >30mmol)

• Absence of ketones (or + or ++ only)

• Serum osmolality >350mmol

How do you calculate osmolality?

2(Na+K) + urea + glucose

Or

Ask for a serum level (U and E bottle, biochemistry)

Clinical features

• Possibly osmotic symptoms

• Dehydration around 10L deficit

• decrease LOC

• signs of underlying infection in upto 50%

• +/- thrombo-embolism in up to 30%

• 2/3 cases previously undiagnosed

• As high as 50% mortality

Is the treatment the same as DKA?

• Fluid replacement – SLOWER (may be a marker of population not pathology)

• Electrolyte replacement (pseudohyponatraemia)

• Insulin – ‘slower’ scale• Search for cause• ANTICOAGULATION • Monitor

HYPOGLYCAEMIAzero tolerance

• Definition: is a plasma glucose of<3mmol/l

• Requires immediate treatment

or

Low blood glucose level with symptom complex

or

Requiring 3rd party rescue

Symptoms

• Fall in glucose triggers fixed hierarchy of events:

• 1) inhibition of insulin secretion

• 2) release of glucagon and adrenaline (~3.8mmol/l)

• 3) hypoglycaemic symptoms (~3.0mmol/l)

All the above responses are diminished especially Glucagon Response

Symptoms

• Autonomic

• sweating, palpitations, tremor,hunger

• Neuroglycopenia– confusion, clumsiness, behavioural changes

• Non-specific – nausea,headache

Aetiology

• Reactive Hypoglycaemia– Post prandial

– gastric surgery

• Drug Induced– insulin

– sulphonylureas

– alcohol

Fasting• P- pituitary failure• L- liver disease• A- Addison• I - Islet cell tumours• N- neoplasm-

retroperitoneal fibro sarcomas

Treatment of hypoglycaemia

• If able to eat– glucose: e.g 3 dextrosol tabs / 200mls of orange juice/

coca cola– followed by long acting carbohydrate eg toast/

sandwich

• In a semi-conscious patient

• In the community: 1mg glucagon im and long acting carbohydrate on recovery

Severe Hypoglycaemia• Consider in any unconscious patient, those

with CVA or odd behaviour• Hospital options-

– I.M. glucagon 1mg– I.V. 20% [50%*] dextrose (typically 50 ml)

• Other options- Hypostop gel• Look for precipitants/causes and avoid• Psychological consequences• Review oral hypoglycaemic drugs• Driving precautions and regaining

awareness*Extravasation of 50% dextrose can cause severe tissue loss; 20% preferable

An example

A 39 year old man is brought in by his wife. He is dehydrated and a little confused. He is not known to be diabetic but his BM on arrival is 25mmol.

Further information

• Serum glucose 24 mmol• Urine ketones ++• Blood gas - machine broken• Bicarbonate awaited

Is this DKA or HONK?

His wife is present. What questions might you ask her to help you work out what is going on?

Diagnosing DiabetesStage Fasting plasma

glucose Random plasma glucose

OGTT

2hr plasma glucose

Normal <6.1mmol/l <7.8mmol/l

Impaired Fasting

Glycaemia

≥ 6.1 and <7.0

Impaired Glucose

Tolerance

≥7.8 and <11.1

Diabetes ≥7.0 (2 readings) ≥11.1mmol/l

+Symptoms

>11.1mmol/l

Any questions about diabetic

emergencies?