1. Dr Emma Hodgkins, FY1

2.  Globally 285 million people currently have diabetes, which is estimated to double by 2030.  UK prevalence 4.5% (5.5% in England)  Diabetes is currently the fifth most common reason for death in the world.  Around 1 in 8 people between 20 and 79 years old have their death attributed to diabetes and it is expected to rise.  The life expectancy on average now is reduced by: More than 20 years for people with Type 1 diabetes Up to 10 years for people with Type 2 diabetes

4.  Fasting Glucose > 7mmol/L  Random glucose >11.1 mmol/mol  2h glucose >11.1 in an OGTT  HbA1c > 6.5% (48 mmol/mol) ‘Pre-diabetes’  Impaired glucose tolerance = 2h glucose 7-11.1  Impaired fasting glucose = fasting 6.1-7.0

5.  Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes C ontrol and Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications by 25%.  Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1% are:  19% less likely to suffer cataracts  16% less likely to suffer heart failure  43% less likely to suffer amputation or death due to peripheral vascular disease New = [Old % - 2.15] x 11 Old % = [New ÷ 11] + 2.15

7.  Diagnostic criteria: all three of the following must be present  capillary blood glucose above 11 mmol/L  capillary ketones above 3 mmol/L or urine ketones ++ or more  venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L

8. Fluid replacement 1L NaCl over 1 hr 1L NaCl with KCl over 2 hours, 1L NaCl with KCL over 2 hours 1L NaCl with KCl over 4 hours Add 10% glucose 125ml/hr if blood glucose falls below 14 mmol/L Potassium Replacement Serum K > 5.5 Nil K 3.5-5.540mmol/L K < 3.5 Seek Sr review Insuin : Fixed rate insulin infusion (AFTER setting up IV fluids) (0.1unit/kg/hr) 50 insulin (Actrapid® or Humulin S®) made up to 50ml with 0.9% sodium chloride solution Aims of treatment: Rate of fall of ketones of at least 0.5 mmol/L/hr Blood glucose fall 3 mmol/L/hr Maintain serum potassium in normal range Avoid hypoglycaemia

9.  AKA Hyperosmotic Hyperglycaemic state (HHS)  Veinous access, bloods, blood cultures, blood gas  1L NaCl over 30 mins  Insulin therapy  Aim to reduce glucose levels slowly, by approximately 3 mmol/hour.Patients with HHS are often exquisitely sensitive to insulin and require much lower doses than in (DKA).  Mortality 10-20%

11.  If Low GCS:  Protect Airway, 15L O2  IV access  50l 50% glucose STAT  (100 of 20%, 200 of 10%)  For large insulin OD give 1mg of glucagon SC/IM/IV  Should respond in 10 min  1L 10% glucose over 4-8h  Aim for BM > 5  If GCS 15  Oral glucose (120ml lucuzade, HYPOSTOP/ Glucogel)  This only lasts 1h so give a sandwich too!  Monitor finger prick glucose 1-2 hrly until stable

13.  Commonest cause of blindness in under 65s  Background  Microaneurysms (Dots) Blot Haemorrhages, Hard Exudates (lipid leaked from aneurysms)  Pre-proliferative  Cotton-wool spots, Beading & looping

14.  Proliferative  New vessels around the disc & peripherally  New vessels on the iris (rubeosis)  End Stage  Vitreous haemorrhage, scarring, retinal detachment Urgent Referral: Fall in acuity, 1 cotton wool spot, 3 blots, New vessels

16. Hyperglycaemia Mesangeal Proliferation Nephron loss Activation of RAAS Glomerular Hypertension Hyperfiltration of protein Microalbuminaemia Proteinuria Tubular damage Cytokine adtivation Inflammation Glycation of proteins Thick BM

17.  Combination of peripheral vascular disease & neuropathy  Lack of sensation to heat and trauma  foot ulcers  Impaired healing  Charcot foot: osteoporosis, fracture and inflammation – often presents as a hot swollen foot after minor trauma  Increased risk of osteomyelitis necrosis, gangrene & amputation

23.  ABC of diabetes  Oxford handbook of the foundation programme  Oxford handbook of clinical medicine  Dr Clarke- Medicine  http://www.bsped.org.uk/clinical/docs/jbdsdkaguidelines_may 11.pdf DKA guideline http://www.bsped.org.uk/clinical/docs/jbdsdkaguidelines_may 11.pdf  http://www.bsped.org.uk/professional/guidelines/docs/DKAGu ideline.pdf Paeds DKA http://www.bsped.org.uk/professional/guidelines/docs/DKAGu ideline.pdf