acute complications of Diabetes Mellitus

Slide 1: 

Dr Kabamba NL (ICU), Dr Mbuilu JP (Diabetes Clinic) Brain Storming, Dec 2010 Mafikeng Provincial Hospital North West, South Africa DKA & HHS: Management

DKA : 

DKA may herald the onset of type 1 diabetes Most often result of intercurrent illness With failure to adjust insulin or to maintain adequate hydration Pneumonia (Klebsiela +++), UTI, sepsis, Stroke, AMI, Aggressive treatment have improve the out come Remind

DKA : 

DKA DKA typically involves deterioration during several days, with advancing polyuria and polydipsia Weakness, lethargy, nausea, anorexia and the classic periumbilical abdominal pain Physical examination: sign related to the dehydration and acidosis Remind

DKA : 

DKA Physical examination: sign related to the dehydration and acidosis Dry skin and mucous Reduced jugular venous pressure Tachycardia, orthostatic hypotension Depressed mental function Kussmaul respirations Remind

DKA : 

DKA Urines: ketonuria, nitrate + Blood: Glucose greater than 13 mmol/l Ketones present and high, osmolarity ABG: low bicarbonate , low pH (<7,2), K+ high, Na+ low, Anion gap elevated (Na + K) – (Cl + HCO❸ )> 13 mEq/L FBC, CXR, ECG Diagnosis

DKA : 

DKA DKA severity & HHS

DKA : 

DKA Close monitoring first 48H Fluids – correct dehydration Insulin – correct hyperglycemia Electrolytes imbalance: K, Na Correction of acid-base balance Infection or others co-morbidity (AMI…) Management targets

DKA : 

DKA Presence of mild sign of dehydration mean that at least 3 litres of fluid already have been lost Initial correction >> euvolemia—NS or RL, When the patient is euvolemic, …may switch to Hypotonic if hypernatremia exist Dextrose 5% with half isotonic sodium chloride (Maintelyte) when B. Sugar < 10 mmol/L First 3 litres must be absorbe in the 4 hours then 1L/4 Hourly depend on CVP Fluid management:

DKA : 

DKA Short acting insulin, IV or IM not s/c – absorption reduced because of dehydration Intensive insulinotherapy induice hypoKaliemia and hypoglycemia! ... Down regulation Initial 0.1 U/Kg/h >>> 6U/h >>> 24U + 60 ml NS>->15 ml/h Until B.Sugar < 10 mmol/L 2-3 U/h until Ketoacidotic state abates Use large volume of NS when pump not available! Eg 60u in 500 ml of NS rate 50 ml/h flow-metre! Insulinotherapy

DKA : 

DKA Potassium > 6 mEq/L no K supplement 4,5 - 6 repeat hourly 3 - 4,5 20 mEq/h In severe hypoK hold insulin! Acid-base balance Electrolytes

DKA : 

DKA Acid-base balance Sodium bic is infused when acidosis start to threaten the patient life 100 – 150 ml of 1.4% in 30 min may be repeated Early correction of acidosis with Na Bic, may worsen hypokaliemia and cause paradoxical cellular acidosis Electrolytes

Hyperosmolar Nonketonic Status (HnS) : 

Hyperosmolar Nonketonic Status (HnS) HHS +++ DM T2, initial presentation in 30-40 % The mortality remain high: ranging from 14-58% …old age, concurrent illness,dehydration Cerebral oedema is rare, ARDS is seen, Average age is 60 years (57-69) HNS ususlly evolves over a period of days to weeks, as opposed to DKA which develops over the course of a few days REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) +++ DM T2 Impaired mental status and elevated osmolality in a hyperglycemic patient Criteria include: Serum Osmolarity of 320 mOsm/kg B. Sugar > 33.3 (Hi) Profound dehydration, no ketoacidosis; pH of 7.3, HCO3 greater than 15 and absence of severe ketosis REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Increasing thirst with polyuria, polydipsia and weight loss History of comsumption of beverage containing glucose…juice, soda DMT2 Tachycardia---early stage of dehydration Fall of urine output--- moderate to severe dehydration Hypotension ∆∆ sepsis REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) HHS may be associated with several neurological finding: Seizures, aphasia, paresis, myoclonic jerks DD include DKA, AMI, P. Embolism Laboratory studies Glycemia greater than 55 Glycemia proportional to the degree of dehydration Monitor glycemia hourly during the first 24-48 hours of treatment REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Laboratory studies ABG pH= 7.3 or higher, hypoxemia – ? cardiac or lung diseases Hypocarbia - ? Due to tachypnea Plasma ketones : mild, correct rapidly Serum osmolality > 320 mOsm/l REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Serum osmolality > 320 mOsm/l Osm= 2Na + 2K+ Glucose Wide anion gap Electrolytes Wcc , CXR, ECG- T waves and QT intervals, CT scan Brain CVP REMIND

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Intravenous fluid and electrolyte homeostasis NS 2litres over first 2 hours replace the half of the estimated volume deficit in the first 12 hours of therapy, the remaining in the next 12 H Once renal perfusion is accomplished, as evidenced by adequate urinary output, 0,45% saline may be used for continued hydration Management

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Intravenous fluid and electrolyte homeostasis Switched back to NS 0,9% or RL when osmolality is less than 320 mOsm /l Use Maintelyte (NS 0,9% + Dextrose 5%) when the plasma glucose is less than 17 mmol/l Urinary output (catheter) is the best monitor-tool for hydration state, with BP, CVP…! Management

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Intravenous fluid and electrolyte homeostasis R/L reduce the use of potassium, monitor 4 hourly! Anticipate replacement when K is less than 5 mEq/l Phosphate, magnesium and calcium are not replaced routinely, but a symptomatic patient with tetany requires replacement therapy Management

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Correction of hyperglycaemia Immediate treatment with insulin is contraindicated in initial treatment! After kidney show evidence of being perfused: insulin IV/IM 0,5 – 1 u/Kg/h pump Target of intensive treatment Glucose= or less than 15 mmol/l General target DM type2 4,4 – 7 mmo;/l >>HbA1c=7 Management

Hyperosmolar Hyperglycaemic Status (HHS) : 

Hyperosmolar Hyperglycaemic Status (HHS) Correction of hyperglycaemia Usually insulin is used for several weeks before switching to oral treatment Treatment od underlying disease ? Cardio-respiratory support antibiotics Management

Thank you : 

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