| What are the acute complications of DM? | Diabetic Ketoacidosis (DKA)
Hyperglycemia Hyperosmolar state (HHS) |
| What is DKA? | Most common cause of hospitalization of young diabetic pt (10-14% of pt) and 30% of them are diagnosed with diabetes post hospitalization for DKA.
Mortality 5%
It should be directly managed |
| Define DKA? | Acute complication of IDDM (type 1 diabetes) caused by an absolute lack of insulin or lack of its action
Characterized by: acidemia, ketonemia, hyperglycemia, hyperosmolarity, osmotic diuresis, dehydration. |
| What are the usual criteria of dx of DKA? | serum glucose (>250 mg/100ml)
bicarbonate (<15meq/l)
serum ketones (>5mmol/l)
pH <7.3 |
| How is the pathogenesis of DKA? | When Insulin is completely blocked, it will cause glucopenia in cells (lack of glucose) so we have more gluconeogenesis and glycogenolysis causing hyperglycemia, and thus osmotic diuresis.
In parallel we have use of other energy source which is lipolysis, which will give free fatty acids that will get oxidized into ketone eventually. |
| What are the precipitating factors of DKA? | Not knowing of the dx of IDDM
Non-compliance to treatment
Infections
Acute medical problems (surgery, CAD...)
Emotional stress
Drugs (interfering with insulin secretion like steroids, thiazide...)
Maybe no apparent factor, it just happens |
| What are the typical history presentations for a DKA patient? | Some with coma, change of treatment, fever, infection, drug intake (steroids), alcohol ingestion |
| What are the symptoms of DKA? | Hyperglycemia (polyuria, polydepsia, dry tongue, weakness, malaise, headache, drowsiness, muscle cramps, weight loss...)
Acidosis (abdominal pain, nausea, vomiting, constipation, SoB, deteriorated consciousness. |
| What are the signs of DKA? | Vitals (low bp, rapid weak pulse, high temp if infection, long deep sight with acetone smell breathing (Kussmaul breathing)
Dehydration signs (dry tongue)
Abdominal tenderness and rigidity
Muscle weakness
Hemiparesis (inability to move a side of the body) |
| What are the lab findings in DKA? | Very high blood sugar (250-700 mg/100ml)
ketone, pH<7.3, low bicarb (increased anion gap)
Water and electrolyte deficits (except potassium high since usually its intracellular but to compensate it goes out)
Hyperlipoporteinemia, enzyme abnormalities (ALT and AST and amylase), BUN increased by dehydration, CBC (leukocytosis) |
| What is the tx of DKA? | Hydration (for dehydration)
Insulin (for other complications)
If unconscious put NS or dextrose if sugar low after insulin uptake (if sugar reached <250 mg)
1L for half an hour, then 1L for an hour then 1L for 2 hours |
| How is insulin given in case of DKA? | Simple insulin is given IV (push/drip/pump)
Glucose falls differently for each pt, rehydration alone reduces glucose, infection decreases the rate of decrease by 50%
4-6 hours glucose falls to 200-300 mg/dl
8-12 hours correct the acidosis
Regimen is 0.2 u/kg IVP, then 0.1 IV every hour till pt is out of acidosis, if pt glucose doesnt decrease by 10% then repeat loading dose of 0.2
Usually when first admitted to hospital we give immediately acting insulin |
| How do we replace deficits due to DKA? | Na (NS), K (it decreases with treatment, replace it orally for 1 week)
P (uncertain benefits of replacement, usually for people with anemia/ cardiac issues)
Mg (replacement if under <1.2mg/dl) |
| How to treat acidosis using bicarbonate? | usually with severe acidosis (pH<7), should be given in small amounts, monitor and stop giving bicarb at pH=7.15-7.2
Since rapid alkalinization could cause hypokalemia, paradoxical CNS acidosis, effect on oxygen delivery to tissues (O2 saturation curve goes to the right) |
| What are the general measures taken in case of DKA? | Coma give oxygen if needed (intubation or respirator), bladder catheter if needed and low dose heparin if osmolarity >380mosml (hyperosmolar) |
| What complications could accompany the tx of DKA? | Hypoglycemia, hypokalemia, hypoxia and lactic acidosis, brain edema |
| How does tx of DKA cause hypoglycemia? | with hydration and insulin since glucose fall rapidly (more than ketone) so we stop giving insulin before pt stops being acidotic
To prevent it change NS to D/NS IV when sugar falls <250 mg/dl with giving insulin IV |
| How does Tx of DKA cause hypokalemia? | If K is not replaced, we should monitor K every 2 hours.
symptoms are muscle weakness, paralytic ileus, cardiac depression, cardiac arrest
Flat or inverted T wave and a prominent U wave on the EKG |
| What are the complications of bicarbonate Rx? | Severe hypokalemia, Supressed hyperventilation and CO2 retention and thus CSF acidosis and brain edema, decrease in peripheral oxygenation and thus lactic acidosis |
| How does the Rx of DKA cause brain edema and how to treat it? | Accumulation of glucose in plasma, leads to acidosis in CSF and agressive hydration and rapid correction of acidosis will cause edema in brain.
Treated with mannitol, decreased fluid intake and steroids (dexamathasone) |
| How do we prevent DKA? | Education, contacting physicians with symptoms, insulin tx, sugar and ketone level monitoring, Abx if infected, avoid precipitating factors and drugs |
| What is Hyperglycemic Hyperosmolar State (HHS)? | Acute complication of T2DM, characterized by extreme hyperglycemia with dehydration, occurs in elderly
Pathogenesis same as DKA but without lipolysis --> no ketosis |
| What causes the absence of ketosis for HHS? | Lower levels of couner regulatory hormones, or lower FFA, or liver is less capable to form ketone, or insulin/glucagon ratio doesn't favor ketoacidosis. |
| What are the PPT factors for HHS? | Elderly (with no adequate water intake), CVA, MI, infection, renal failure, drugs (steroids, mannitol, diuretics...) |
| What is the clinical presentation of HHS? | more insidious than DKA (gradual but harmful), signs and symptoms of dehydration and hyperglycemia, more prominent CNS symptoms than DKA, infection S&S |
| What are the lab findings in case of HHS? | Sugar >600 up to 1000
high serum osmolarity >330
No acidosis or mild metabolic one >7.3 |
| What is the tx for HHS? | Urgently treat since MR=50%, Give IV fluids (10L), give insulin, and electrolytes + Abx if infection. |
