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Management of Diabetes Emergencies''
Management of Diabetes Emergencies''
EMERGENCIES
Dr. F. O. Finomo
Diabetes mellitus
A syndrome/group of diseases
characterized by hyperglycemia and
disturbances of carbohydrate, fat and
protein metabolism due to defects in
insulin secretion, insulin action or both
Acute Complications of Diabetes
(Diabetic Emergencies)
D ia b e te s
D ia b e tic K e to a c id o s is H y p e rg ly c e m ic H y p e ro s m o la r S ta te H y p o g ly c e m ia
H y p e rg ly c e m ia H y p e rg ly c e m ia
A c id o s is w ith a n io n g a p N o a c id o s is
E le c tro ly te D is tu rb a n c e s H y p e rn a tre m ia a n d o th e rs
DIABETIC KETOACIDOSIS
• Definition
• Epidemiology
• Aetiopathogenesis/Pathophysiology
• Clinical features
• Investigations
• Treatment
• Prognosis
Definition
• An acute metabolic complication of DM with
uncontrolled catabolism associated with insulin
deficiency aggravated by ensuing
hyperglycemia, dehydration, and acidosis-
producing derangements in intermediary
metabolism and characterized by:
– Hyperglycaemia (>200mg/dL, 11mm/L)
– Acidosis, blood pH <7.3 , HCO3- < 15mmol/L
– Increased total blood ketones, > 3mmol/L
– In clinical practice it is suspected when there is
ketonuria++ in the face of hyperglycaemia
Epidemiology of DKA
• It is the most common endocrine emergency.
• Few published Nigerian data
• Europeans and Americans quote 10 – 30 cases per
100, 000 population.
• Commoner in females
• Commoner in non-whites
• Mortality higher in the elderly
• Commonly seen in type 1 Diabetes, but may occur
in type 2 Diabetes.
• Mortality is around 2-5% in developed world, it is as
high as 20-30% in the developing countries
Precipitating factors
Newly diagnosed diabetic (20-30%) especially type 1
-↑ counter-regulatory hormones
-↑renal gluconeogenesis
Restore perfusion/rehydration
Avoid Complications
4.5 – 5.4 13
3.5 – 4.4 26
<3.5 39
• Continue oral potassium supplementation for
5-7 days when the patient can take orally.
Avoid complications:
• Complications of the disease; hypotension, ARF, coma,
aspiration pneumonia, orthostatic hypotension,
cerebral oedema, DVT, hypothermia, ARDS.
Sy m pt o ms c/w Hy p ogly c emia Low Ser u m Blo od Glu cos e Relie f of Sy m pt o ms wit h Nor m aliz a t io n of BG
Pathophysiology
• As plasma glucose decrease just below
the physiologic level, Glucagon increases
which in turn increases hepatic
glycogenolysis and hepatic and renal
gluconeogenesis. This is the 2nd
defense.
• With further reduction - epinephrine is
released from adrenal medulla which
acts like Glucagon as well as increase
delivery of gluconeogenic substrates
from fat cells and muscles. This is the
3rd defense.
• Beyond 4 hrs, Cortisol & growth hormone
also support glucose production and limit
utilization
.
• With persistent low levels, symptoms
prompt the behavioral defense against
hypoglycemia, including ingestion of food.
Neuroglycopenic Neurogenic/Autonomic
• Altered mental status • Adrenergic
– Palpitations
• Confusion
– Tremor
• Fatigue – Anxiety
• Seizure
• Loss of consciousness • Cholinergic
• Death – Diaphoresis
– Hunger
– Paresthesias
classification
Based on severity
-Mild: autonomic symptoms are present.
-Moderate : autonomic and neuroglycopenic symptoms are
present
-severe: autonomic and neuroglypenic symptoms are present,
may become unconscious, plasma glucose is usually < 2.8mmol/L .
Diagnosis
• History and examination
• History of clinical presentation suggestive of
hypoglycemia
• Assess risk factors and identify etiology
• Diagnosis is mainly based on Whipple's triad
• A high index of suspicion, awareness of etiology
and obvious clinical manifestations should
prompt a quick bedside blood glucose
determination using a Glucometer.
• Investigation - laboratory diagnosis
Investigation
• FBC
• Insulin assay
• C-peptide assay
• Drug screen - sulfonylurea, metformin
• Serum electrolyte/urea/creatinine
• Liver function test
• Hormonal assay - GH, Cortisol
Management
Acute intervention
Hypoglycemia is a medical emergency.
•Admit patient
•Resuscitation: ABC
•Secure iv access
•IV bolus 50mls of 50% Dextrose water (in double
dilution)
•NOTE: In absence of 50% D/W, 250mls of 10% D/W, or
500mls of 5%D/S can be given.
•Re-assess the blood glucose in 30minute time then 1
hour time
Maintenance therapy
- Continuous glucose administration and frequent
monitoring.
• Sepsis
• Stroke
• Metabolic abnormalities - DKA
• Electrolyte derangement
• Congestive cardiac failure
• Liver failure
• Renal failure
Conclusion
• Insulin Excess
– Incorrect dosing/wrong timing/type
– ↓ PO intake: illness, fasting
– ↑ glucose utilization: exercise
– ↑ sensitivity peripherally to insulin: weight loss,
exercise
– ↓ endogenous production
– ↓ insulin clearance
Management
Urgent random blood sugar estimation is
mandatory.