DIABETIC EMERGENCIES

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DIABETIC EMERGENCIES

• Dr A Panahloo

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www.sghms.ac.uk / addison
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• 1. Diabetic Ketoacidosis
• 2. Hyper-osmolar non-ketotic coma (HONK)
• 3. Hypoglycaemia

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Diabetic Ketoacidosis (DKA)

• Definition
• Severe uncontrolled diabetes requiring
  emergency treatment with insulin and IV fluids,
  and with a blood ketone body (acetoacetate and
  3-hydroxybutyrate) concentration gt5mmol/l

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Diabetic Ketoacidosis (DKA)

• Biochemical features
• Hyperketonaemia
• Metabolic acidosis
• Hyperglycaemia

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Incidence and mortality

• Annual incidence 1-5 episodes per 100 Type-1
  diabetic patient
• Peak in adolescence
• Twice as common in females
• Average mortality 5-10
• Mortality rises with age, 50 gt 80 years

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Precipitating Factors

• Infection (30)
• New cases of type-1 diabetes (10)
• Insulin error (patient or doctor) (13)
• Myocardial infarction (1)
• Unknown cause (40)
• Miscellaneous (6)

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Differential Diagnosis Causes of anion-gap
acidosis

• Ketoacidosis
• Type-1 diabetes
• Alcoholic abuse
• Starvation (acidosis is mild)
• Lactic acidosis
• Chronic renal failure
• Drug toxicity
• Methanol (metabolized to formic acid)
• Ethylene glycol (metabolized to oxalic acid)
• Salicylate poisoning

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Clinical features-symptoms

• Polyuria and polydipsia
• Weight loss and malaise
• Weakness
• Anorexia
• Blurred vision
• Nausea and vomiting
• Abdominal pain, especially in children
• Breathless (acidotic respiration)
• Confusion and drowsiness
• Coma (10 of cases)

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Clinical signs

• Dry mouth
• Facial flush
• Ketotic breath
• Postural hypotension
• Tachycardia
• Kussmaul breathing (deep rapid resps.)
• Depression of consciousness
• Coma

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Fluid and Electrolyte Depletion

• Sodium 500 mmol
• Chloride 350 mmol
• Potassium 300-1000 mmol
• Calcium 50-100 mmol
• Phosphate 50-100 mmol
• Magnesium 25-50 mmol

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Management

• Rapid confirmation of diagnosis
• BM,smell ketones,urine ketostix
• Blood
• Glucose, UE,FBC,gases, blood cultures
• Look for precipitating cause eg infection
• Asses severity of dehydration
• If comatosed nurse in coma position, naso-gastric
  tube and urinary catheter

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Other Investigations

• Ketone bodies
• ECG
• Chest X-ray
• Urine and sputum for culture

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Management

• Fluid replacement
• Insulin
• Correction of electrolyte imbalance

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Fluids

• Deficit my be 5-10 litres
• If systolic BP lt 100mmhg or shocked
• colloid or 500 mls N/saline over 15 min
• then 1000 mls N/saline over 1 hour (no K)
• If not shocked
• 1000 mls N/saline over 1 hour

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Fluids

• Continue N/saline K according to need
• Asses BP, CVP and urine output
• Repeat Glucose, UE, blood gases
• 4 hourly
• Convert to 5 dextrose infusion when BG lt 15 mmol

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Insulin

• Soluble insulin via a pump
• No indication for bolus dose or s/c or IM
  injections
• No indication for sliding scale
• Aim to reduce glucose by 3 mmol/h
• When glucose lt15 mmol use dextrose
• Continue insulin and dextrose until acidosis
  clears

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Potassium

• Total deficit may be very high
• K is intracellular, insulin and rising pH cause
  entry of K in cells
• Serum levels may be high, low or normal and do
  nor reflect total body status
• Main danger hypokalaemia
• Replace 20-40 mmol K per litre of fluid

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Bicarbonate

• Controversial
• Contraindicated unless severe acidosis
  cardio-respiratory collapse imminent
• Shifts K into cells
• Worsens hypokalaemia
• CO enters brain reduces CSF pH
• Cerebral oedema results
• adverse O2 tissue delivery

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Complications

• Cerebral oedema
• Arterial and venous thrombosis
• Secondary infection in urine, chest
• Adult respiratory distress syndrome
• Thrombophlebitis
• Rhabdomyolysis

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Prevention

• Sick day rules
• Never stop insulin and check for ketones
• Measure BMs 4 times a day
• If BM lt 11 mmol continue normal insulin
• If BM 11-17 mmol add extra 4 u with meals
• If BM gt 17 mmol add extra 6 u with meals Drink
  milk, fruit juice, 5 pints sugar free fluid /day
• If nausea and vomiting and BM gt17 call Dr.

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Hyperosmolar non-ketotic coma(HONK)

• Non-ketotic hyperglycaemia
• Relative insulin deficiency
• BG much higher than DKA (gt50 mmol)
• Develops slowly over weeks
• Severe dehydration
• Impaired Consciousness
• High serum Na gt150 mmol/l

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HONK- Diagnosis

• Raised plasma glucose (50- 100 mmol)
• Increased plasma osmolality (gt 340 mosm/l,
  measured in lab or calculated
• P.osmolality (mosmol/l)
• 2 x plasma Na plasma K plasma glucose
  plasma urea
• No ketosis and no acidosis

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HONK- incidence and mortality

• Accounts for 10-30 of hyperglycaemic emergencies
• Mortality 30 due to associated conditions and
  complications
• Most patients age gt50 years
• Higher incidence in Afro-Caribbean patients
• 50 undiagnosed diabetes

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HONK- Clinical features

• Develops over several weeks
• Polyuria, polydipsia
• Gradual clouding of consciousness
• Severe dehydration
• Hypotension
• Reversible neurological signs
• Comatosed

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Comparison DKAHONK

• DKA HONK
• AGE YOUNG TYPE-1 OLDER TYPE-2
• CAUSE INSULIN DEFFICIENCY DIURETICS
• STEROIDS
• 50 UNKNOWN DM
• Na NORMAL / LOW HIGH
• GLUCOSE lt 40 mmol gt 40 mmol
• BICARBONATE lt 14 mmol/l NORMAL
• KETONES POSITIVE NEGATIVE
• MORTALITY 5-10 30-50
• COURSE TYPE-1 OFTEN DIET ALONE

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Fluids in HONK

• Initial fluid, electrolyte and insulin therapy is
  similar to DKA
• If Na gt150 mmol/l half normal saline
• Patients more sensitive to insulin
• Start insulin infusion at slower rate
• eg 3 units / hour
• Fewer K problems
• Anticoagulation

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Hypoglycaemia

• Common side-effect of treatment with insulin or
  sulphonylureas
• Does not occur with Metformin or diet alone
• Each year 25-30 of all insulin treated patients
  have one or more episodes of severe hypoglycaemia

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Hypoglycaemia

• Predisposing factors
• Inadequate food intake
• Excess dosage, error by patient or Dr
• Exercise
• Weight loss
• Alcohol
• Adrenocortical, thyroid or pituitary failure
• Renal failure

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Hypoglycaemia

• Asymptomatic (biochemical), awake or asleep
• Mild symptomatic- patient able to treat
  themselves
• Severe symptomatic- help needed to treat
  hypoglycaemic attack
• Coma

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Hypoglycaemia- hierarchy of events

• Blood glucose
• 4.6 mmol Inhibition of insulin secretion
• 3.8 mmol Release of glucagon and adrenaline
• 3.0 mmol Hypoglycaemic symptoms
• lt 2.8 mmol Cognitive function progressively
  impaired

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Hypoglycaemia - symptoms

• 1. Autonomic
• Sympathetic or parasympathetic
• eg sweating, palpitations, tremor or hunger
• 2. Neuroglycopenic
• eg confusion, clumsiness, behavioural changes,
  temper tantrums in children

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Hypoglycaemia - symptoms

• Acute
• Lassitude
• light headed
• tremor
• restless
• cold sweat (diversion of blood from skin and
  kidneys to brain, liver and muscle)

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Hypoglycaemia - symptoms

• Sub-acute
• Slow movement and thoughts
• Immobility
• Slow speech
• Detachment
• Automatism and amnesia
• Confusion
• Drowsy
• Manic

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Hypoglycaemia - symptoms

• Chronic
• Rare
• Obsessional control of diabetes
• Symptoms absent
• Personality disorder
• Apparent dementia

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Hypoglycaemia - treatment

• Mild
• Treat immediately with oral glucose (15-20g)
• If patient unable to swallow
• IV 50 dextrose 30-50 mls)
• IM glucagon (1mg)
• Patients should recover immediately
• Failure to recover may be due to cerebral oedema,
  postictal state or other causes of coma

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Hypoglycaemia - treatment

• Hypoglycaemia induced by sulphonylureas may be
  very prolonged
• May need IV glucose for hours or even days