Diabetic Emergencies

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Diabetic Emergencies

• Dr. Mohamed Suliman

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Diabetic Emergencies

• Common
• Acute hyperglycaemia with no acidosis
• Hypoglycaemia
• DKA
• Less common
• HONK
• Lactic Acidosis

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Mortality

• DKA Mortality 2-5
• Cause of death
• - DKA
• - Underlying cause of DKA, e.g
  infection, MI
• - complications of treatment e.g
  cerebral oedema, hypokalaemia
• HONK mortality 15
• Lactic Acidosis mortality up to 50

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Acute hyperglycaemia with no acidosis

• Known diabetic (type 1 or type 2)
• Acute intercurrent illness e.g infection
• Drugs e.g steroids leading to
  deterioration in control
• Newly diagnosed type 1 diabetes

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Management of acute hyperglycaemia in a known
diabetic

• Rule out DKA and HONK
• Is the patient unwell/unstable? e.g vomiting,
  dehydrated
• If yes admit and stabilise (IV insulin sliding
  scale, IV fluids)
• Treat underlying cause e.g infection
• If no arrange review by DSN/diabetes team and
  discharge

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Newly diagnosed diabetic with no DKA

• Features suggesting type 1 diabetes
• Marked osmotic symptoms (polyuria, polydepsia,
  weight loss)
• Short history (days to weeks)
• Younger age (lt30 years old)
• Ketonuria
• BMI lt25

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Management of newly diagnosed type 1 diabetic
with no DKA

• Is the patient unwell/unstable ?e.g vomiting,
  dehydrated
• Yes treat as in-patient with IV insulin until
  eating and drinking
• No early discharge after review by DSN/diabetes
  team

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Pathogenesis of DKA and HONK

• Pathogenesis of DKA is better understood than
  that of HONK
• A reduction in the net effective concentration
  of insulin
• Elevation in counter-regulatory hormones
  (Glucagon, Cortisol, GH, catecholamines)

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DKA

• Absolute Insulin deficiency

Lipolysis
Hyperglycaemia
Ketones
Dehydration
Metabolic acidosis
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HONK
Relative insulin deficiency
Reduced thirst
Minimal/absent ketogenesis
Hyperglycaemia
Dehydration
Hyperosmolality
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DKA or HONK?
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What are the precipitating causes of DKA?
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DKA clinical presentation

• Symptoms
• Vomiting
• Abdominal pain
• Shortness of breath
• Symptoms of precipitating condition
• Signs
• Dehydration
• Tachycardia and hypotension
• Hyperventilation (Kussmaul respiration)
• Drowsiness/coma
• Ketones on breath

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DKADiagnostic criteria

• Plasma glucosegt14mmol/L
• Urinary ketones gt
• Venous bicarbonate lt 18 and/or arterial pH lt 7.30

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Initial assessment

• Airway
• Consider NGT in a vomiting or
  semi-conscious patient
• Breathing
• Monitor oxygen saturations
• Circulation pulse, BP
• Start IV normal saline (1 L in 1 Hour)
• Contact senior help
• Diagnosis
• Baseline investigations UEs, glucose,
  FBC, venous bicarbonate (or ABGs)

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Should ABGs be done in all patients with
suspected DKA?

• No!
• Consider in those with
• Reduced level of consciousness
• Respiratory distress
• Hypotension
• In patients who appear clinically well, venous
  bicarbonate is enough to confirm diagnosis

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Who to consider for ICU?

• pH lt7.0
• Reduced GCS lt10
• Hypotension (Systolic BP lt90)
• No clinical signs of improvement after 1st hour
  of treatment

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Initial management

• Once diagnosis confirmed, treat according to DKA
  protocol
• IV insulin sliding scale
• IV fluids
• Potassium replacement

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Secondary assessment

• Full history and examination to check for
  precipitating factors
• CXR/ECG and Blood/urine cultures if sepsis
  suspected
• Specific treatments for identified precipitants
  (e.g infection/MI)

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Ongoing review

• Review patient (SHO/SpR) at 1 hour, 2 hours, 4
  hours, and 8 hours and other times if needed
• Repeat UEs and venous bicarbonate (or ABGs) at
  2, 4 and 8 hours

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How much fluids should I give?
Initial evaluation. Start iv fluids 1L of 0.9
saline in 1st hour
Hypovolaemic shock (sBP lt 90)
Cardiogenic Shock
Mild hypotension or normal BP
Haemodynamic monitoring to guide fluid
replacement in ICU
0.9 saline 1 L/hour and/or plasma expander
0.9 saline 500 ml/hour for 4 hours can be
adjusted according to haemodynamic status
Once stabilised
0.9 saline 250ml/hour for next 8hours then
125ml/hour - can be adjusted according to
haemodynamic status
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Which type of fluid should I use?

• Normal saline is the standard replacement
• If corrected sodium gt148 mmol/l use 0.45 saline.
• Corrected sodium
• Plasma Sodium (plasma glucose-6)
  3.5
• When plasma glucose ?14 mmol/l change from saline
  to 5 dextrose
• Fluid deficit is usually 5-8 litres and the aim
  is to replace it in 24-48 hours

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When to consider IV bicarbonate?

• Bicarbonate should only be considered in severe
  acidosis (pH lt7) with impending cardiovascular
  or respiratory collapse
• Usually in an ICU setting
• 500 ml of Sodium bicarbonate 1.26 with 20 mmol
  KCl over 30 minutes

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Insulin

• IV Actrapid 0.15 units/kg (e.g 10 units)
• Commence IV insulin sliding scale adjust
  according to hourly capillary glucose
• Aim to reduce glucose levels by 4-7 mmol/l/hour

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Potassium
Potassium (mmol/l) Action
lt3.3 KCl 40 mmol/l in first hour and
withhold insulin until K gt3.3
3.3-4.0 KCl 40 mmol in each litre of fluid
4.0-5.5 KCl 20 mmol in each litre of fluid
gt5.5 withhold KCl and check every 2 hours
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When do you take down the sliding scale?

• Bicarb gt 18mmol/l and or pH gt 7.30
• Patient is eating and drinking
• Ketonuria 1 or less

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How do you take down the sliding scale?

• Best to take sliding scale down in the morning
  where possible.
• Continue sliding scale for 30mins after first sc
  injection of short-acting insulin
• Ask DSN to see as soon as patient ready to switch
  to sc insulin
• If ketonuria returns reassess need for restarting
  sliding scale

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What subcutaneous insulin regime should you start
the patient on?

• Convert to previous insulin regime if patient
  well controlled prior to admission
• OR
• Calculate insulin requirements over 24 hrs and
  convert to qds regime using Novorapid tds pre
  meal and Insulatard pre bed.
• Give 1/3 total dose insulin as insulatard pre bed
  and the remainder split into 3 Novorapid doses
  pre meal

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DKAPrevention

• Sick day rules
• Continue your insulin when you are not feeling
  well
• If vomiting check glucose levels more frequently
• Take small amounts of CHO in liquid form with
  short-acting insulin
• Seek help early if you continue to feel unwell

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HONKDiagnostic criteria

• Plasma glucose gt 30mmol/l
• Plasma Osmolality gt 320mOsm/Kg
• Urinary ketones
• pH gt 7.30 and HCO3 18
• plasma osmolality 2(Na K) glucose urea

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HONK differences in management form DKA

• On initial assessment check osmolality
• Consider anticoagulation in severe
  hyperosmolality
• Consider 0.45 saline instead of normal saline if
  corrected Nagt148 mmol/l
• Fluid deficit 8-15 litres, aim to replace it over
  48 hours.

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HONK differences in management form DKA

• Patients may be more insulin-sensitive and need
  smaller doses of insulin
• Take sliding scale down when patient is
  clinically better and eating and drinking
• If previously on OHA, continue sc insulin for 2-3
  days before considering restarting OHAs.
• Most patients can eventually be managed on diet
  only or OHAs.

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Hypoglycaemia in a diabetic patient

• Usually caused by insulin or a sulphonylurea e.g
  Gliclazide or Glibenclamide
• Metformin and the Glitazones (Rosiglitazone and
  Pioglitazone) do not cause hypoglycaemia

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Hypoglycaemia in a diabetic patient - symptoms

• Shaking
• Hunger
• Palpitations
• Sweating
• Incoordination
• Visual disturbance
• Nausea
• Malaise
• Confusion
• Drowsiness
• Speech difficulty
• Atypical behaviour

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Hypoglycaemia in a diabetic patient special
considerations in the elderly

• Hypoglycaemia is common in elderly patients
• Symptoms may be unrecognised
• Extra care should be taken with elderly patients
  taking long-acting sulphonylureas e.g
  Glibenclamide

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Hypoglycaemia in a diabetic patient making the
diagnosis

• Establish the diagnosis quickly if practically
  possible by measuring a finger prick capillary
  blood glucose
• A level of lt4 mmol/l suggests that the symptoms
  are caused by hypoglycaemia.
• If there is likely to be any difficulty with
  performing the test
• Treatment should not be delayed.

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Hypoglycaemia in a diabetic patient Treatment

• If the patient is able to take orally any
  available glucose drink.
•  
• Repeat after 5 minutes if no improvement in
  symptoms
• Oral glucose should be followed by complex
  carbohydrates e.g a sandwich.
• Check the blood glucose every half an hour until
  it has risen to over 4 mmol/l.

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Hypoglycaemia in a diabetic patient Treatment

• If oral administration is not possible
•  Intramuscular (or subcutaneous) Glucagon 1 mg
  (treatment of choice )
• After recovery, oral carbohydrate should be
  given.
• If there is no response within 10 minutes,
  intravenous glucose should be administered.

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Hypoglycaemia in a diabetic patient Treatment

• Intravenous glucose
• 50 ml dextrose 50 into a large vein or 100 ml of
  20 dextrose.
• If there is failure to recover consciousness
  within 20 minutes, an intravenous infusion of 10
  dextrose should be started and the blood glucose
  concentration should be maintained between 8-12
  mmol/l.

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Hypoglycaemia in a diabetic patient monitoring
after initial treatment

•  If hypoglycaemia was induced by
• a sulphonylurea
• or
• an intermediate-acting or long-acting insulin
  (e.g Insultard, Humulin I, Lantus, Levemir)
• do regular monitoring of capillary glucose levels
  every 2-4 hours for the following 12-24 hours.

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Hypoglycaemia in a diabetic patient Prevention

•  Reassess diabetes control and targets
• Check HbA1c, glucose levels on home monitoring
• Are control targets appropriate for the patient?
  (e.g elderly, living alone with tight control)
• Adjust treatment
• Re-educate the patient
• DSN review/diabetes team follow up

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Metformin-associated Lactic Acidosis

• Uncommon but potentially fatal complication of
  Metformin treatment
• Metformin is the most widely used diabetic
  medication
• Risk factors renal failure, sepsis, severe
  congestive heart failure, shock

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Metformin-associated Lactic Acidosis- diagnosis

• Features of metabolic acidosis
• Tachycardia,
• Hypotension
• Vasodilatation
• Hyperventilation
• Clouded consciousness
• Features of the underlying precipitating
  problem e.g sepsis, renal failure
• If suspected, check ABGs including lactate level
  (normal lt4mmol/l)

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Metformin-associated Lactic Acidosis- treatment

• Usually very sick patient
• Treat underlying cause e.g sepsis
• Treat in ICU/HDU
• Haemofiltration may be needed for renal failure
  and to eliminate Metformin

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Metformin-associated Lactic Acidosis- prevention

• Stop Metformin in
• patients with creatinine gt150 (eGFRlt30 ml/min)
• patients admitted with severe heart failure,
  hypotension, sepsis
• patients undergoing IV radiocontrast studies

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Questions?