1. DIABETIC EMERGENCIES Dr A Panahloo

2. www.sghms.ac.uk / addison

3. 1.Diabetic Ketoacidosis 2.Hyper-osmolar non-ketotic coma (HONK) 3.Hypoglycaemia

4. 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 >5mmol/l’

5. Diabetic Ketoacidosis (DKA) Biochemical features: Hyperketonaemia Metabolic acidosis Hyperglycaemia

6. 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% > 80 years

7. 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%)

8. 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

9. 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)

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

11. Fluid and Electrolyte Depletion: Sodium500 mmol Chloride350 mmol Potassium300-1000 mmol Calcium50-100 mmol Phosphate50-100 mmol Magnesium25-50 mmol

12. Management Rapid confirmation of diagnosis: – BM,smell ketones,urine ketostix Blood: –Glucose, U+E,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

13. Other Investigations: Ketone bodies ECG Chest X-ray Urine and sputum for culture

14. Management Fluid replacement Insulin Correction of electrolyte imbalance

15. Fluids Deficit my be 5-10 litres If systolic BP < 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

16. Fluids Continue N/saline +K according to need Asses BP, CVP and urine output Repeat Glucose, U+E, blood gases 4 hourly Convert to 5% dextrose infusion when BG < 15 mmol

17. 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 <15 mmol use dextrose Continue insulin and dextrose until acidosis clears

18. 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

19. 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 O 2 tissue delivery

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

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

22. Hyperosmolar non-ketotic coma (HONK) Non-ketotic hyperglycaemia Relative insulin deficiency BG much higher than DKA (>50 mmol) Develops slowly over weeks Severe dehydration Impaired Consciousness High serum Na >150 mmol/l

23. HONK- Diagnosis Raised plasma glucose (50- 100 mmol) Increased plasma osmolality (> 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

24. HONK- incidence and mortality Accounts for 10-30% of hyperglycaemic emergencies Mortality 30% due to associated conditions and complications Most patients age >50 years Higher incidence in Afro-Caribbean patients 50% undiagnosed diabetes

25. HONK- Clinical features Develops over several weeks Polyuria, polydipsia Gradual clouding of consciousness Severe dehydration Hypotension Reversible neurological signs Comatosed

26. Comparison DKA:HONK DKAHONK AGEYOUNG TYPE-1OLDER TYPE-2 CAUSEINSULIN DEFFICIENCYDIURETICS STEROIDS 50% UNKNOWN DM NaNORMAL / LOWHIGH GLUCOSE 40 mmol BICARBONATE< 14 mmol/lNORMAL KETONESPOSITIVENEGATIVE MORTALITY5-10%30-50 % COURSETYPE-1OFTEN DIET ALONE

27. Fluids in HONK Initial fluid, electrolyte and insulin therapy is similar to DKA If Na >150 mmol/l half normal saline Patients more sensitive to insulin Start insulin infusion at slower rate eg 3 units / hour Fewer K + problems Anticoagulation

28. 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

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

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

31. Hypoglycaemia- hierarchy of events Blood glucose: 4.6 mmolInhibition of insulin secretion 3.8 mmolRelease of glucagon and adrenaline 3.0 mmolHypoglycaemic symptoms < 2.8 mmolCognitive function progressively impaired

32. Hypoglycaemia - symptoms 1.Autonomic –Sympathetic or parasympathetic –eg sweating, palpitations, tremor or hunger 2.Neuroglycopenic –eg confusion, clumsiness, behavioural changes, temper tantrums in children

33. Hypoglycaemia - symptoms Acute –Lassitude –light headed –tremor –restless –cold sweat (diversion of blood from skin and kidneys to brain, liver and muscle)

34. Hypoglycaemia - symptoms Sub-acute –Slow movement and thoughts –Immobility –Slow speech –Detachment –Automatism and amnesia –Confusion –Drowsy –Manic

35. Hypoglycaemia - symptoms Chronic –Rare –Obsessional control of diabetes –Symptoms absent –Personality disorder –Apparent dementia

36. 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

37. Hypoglycaemia - treatment Hypoglycaemia induced by sulphonylureas may be very prolonged May need IV glucose for hours or even days