Acute Diabetes Emergencies Ross Buchan, DSN North Glasgow September 2017
Objectives Why is blood glucose important? Hypoglycaemia Hyperglycaemia Acute Diabetes Emergencies (DKA,HONK)
Importance of Blood Glucose control Short term complications Hypoglycaemia Hyperglycaemia DKA / HHS Long term complications Neuropathy Nephropathy Diabetic retinopathy Atherosclerotic disease
Hypoglycaemia
What is Hypoglycaemia? Defined as a lower than normal level of blood glucose A blood glucose of < 4 mmol/l can be defined as hypoglycaemia It can be defined as mild if is self treated and severe if requires third party assistance Regardless of severity of hypo - it should be treated as an emergency (NHS Diabetes, 2010)
Why is hypoglycaemia an increasing problem in our hospitals? 1 in 6 hospital inpatients now has diabetes Of these patients approximately 50% are on insulin therapy Approximately 1 in 4 diabetes patients suffer a hypoglycaemic episode whilst in hospital Serious consequences as this lengthens hospital stay but is also associated with increased mortality
Causes of hypoglycaemia (medical issues) Inappropriate use of quick acting insulin Acute discontinuation of steroids Recovery from acute illness Inappropriate timing of diabetes medications IV insulin infusion running without dextrose infusion Incorrect insulin / dose of insulin prescribed Regular insulin doses being given in hospital when poor compliance ce at home
Causes of hypoglycaemia (Reduced Carbohydrate Intake) Missed or delayed meal Less carbohydrates taken than normal Lack of access to between meal & before bed snacks Prolonged starvation time e.g Nil by mouth Vomiting Reduced appetite
Symptoms of hypoglycaemia Trembling Sweating Anxiety Hunger Palpitations Nausea Tingling Autonomic Neuroglycopaenic Lack of concentration Confusion Weak / Tired Drowsiness Headache Visual disturbance Difficulty speaking
GG&C Hypoglycaemia guideline & Hypo Box
Assesment of hypoglycaemic event Mild - BM < 4mmol/L & displaying autonomic symptoms. Can be self treated Moderate / Severe - BM < 4 mmol/l & possibly displaying both autonomic & neuroglycopaenic symptoms. Requires third party assistance
Mild hypoglycaemia Ensuring patient is orientated, conscious & swallow intact Give 15-20g quick acting carbohydrate eg. Lucozade 200-240ml 240ml or any fizzy sugary juice 150ml Glucojuice 60ml Fruit juice 150-200ml Glucogel 1.5-2 2 tubes or Glucotabs 4-54 5 tablets Repeat BM after 15 mins and if remains < 4mmol/L repeat above up to 3 times. Thereafter discuss with medical staff need for IV Dextrose or 1mg g IM Glucagon
Mild hypoglycaemia Once BM >4 mmol/l give 20g long acting carbohydrate 2 biscuits Slice of bread Glass of milk If near mealtime give next meal
IM Glucagen Glucagen hypokit is an IM injection containing the active ingredient glucagon, which is a hormone produced naturally in the body. Its role is to increase blood sugar levels Not suitable for patient with Type 2 Diabetes
Moderate hypoglycaemia Patient conscious & swallow intact but confused / disorientated / aggressive If able can treat as for mild hypoglycaemia Again repeat up to 3 times before discussing need for IV Dextrose If uncooperative or capable use 1mg IM Glucagon (once only)
Severe hypoglycaemia Patient unconscious / having seizure / aggressive or NBM Check ABC & contact doctor immediately Ensure venous access & give IV Dextrose over 10 minutes as 75ml of 20% Dextrose 150ml of 10% Dextrose 30 ml of 50% Dextrose (avoid) Could also use 1mg IM Glucagon (once only)
Severe hypoglycaemia Recheck BG after 10 minutes if BG < 4mmol/l repeat IV Dextrose As for mild / moderate hypo, once BM > 4 mmol/l give 20g long acting carbohydrate If patient NBM, once BM > 4 mmol/l administer 10% IV Dextrose at 100ml/hr until further assessed by medical staff
Post hypoglycaemic event Think of the cause Check BG frequently post event If treated with insulin, review dose but don t t omit insulin in type 1 diabetes Do not correct a high BG post hypo event
Hypo unawareness Inability to recognise symptoms Associated with strict glycaemic control Prevalence rises with duration of diabetes Risk of severe hypoglycaemia is greater Associated with significat morbidity Range of severity, potentially reversible
Management of Hypo unawareness Aim for less strict control Regular self BG monitoring Education Refer to specialist eg. Secondary care, DSNs
Hyperglycaemia
Hyperglycaemia Blood glucose > 14 mmol/l Symptoms: Polyuria, polydipsia, blurred vision Increased risk of complications Type 1 Ketones / risk of DKA Type 2 risk of HHS (prev HONK)
Ketones Produced when a severe lack of insulin means the body cannot use glucose for energy The body then starts to break down other body tissue e.g fat stores as an alternative energy source Ketones are the by product of this process. A build up ketones can lead to acidosis Most common in Type 1 patients, but can occur in patients with Type 2 Diabetes.
Blood ketones interpreting results <0.6 mmol/l a normal blood ketone value 0.6 1.5 mmol/l indicates more ketones than normal, requiring more insulin > 1.5 mmol/l high level of ketones, risk of DKA, seek medical advice
Causes of Hyperglycamia Illness eg. Infection Increased carbohydrate intake Stress Drugs eg. Steroids Injection sites / technique Denatured insulin
Management of hyperglycaemia Explore causes Optimise treatments Dietary advice Treat illness Education Refer to Specialist Aim for appropriate balance
Diabetic Ketoacidosis (DKA)
What is Diabetic Ketoacidosis (DKA)? Occurs generally in patients with Type 1 Diabetes but also ketosis prone Type 2 patients Hyperglycaemia BG >14 mmol/l (not exclusively) Metabolic Acidosis H+ > 45 Bicarb < 18mmol/L ph < 7.3 Ketonaemia / Ketonuria Major cause of morbidity, Significant mortality rate,
Symptoms of DKA High Blood glucose Presence of ketones Polyuria Polydipsia Lethargy Blurred vision Abdominal pain Nausea / vomiting Kussmauls breathing Smell of ketones on breath (acetone / pear drop smell) Collapse
Causes of DKA Sepsis Trauma Surgery Pregnancy MI Physiological Medications steroids & antipsycotics Psychosocial New diagnosis DM Accidental omission of insulin Deliberate omission of insulin Alcohol Eating disorders Insulin pump failure
Management Aims Fluid resuscitation Estimated fluid loss 6-86 8 litres Insulin IV short acting (Actrapid) + usual basal insulin Potassium replacement Estimated loss 500-1000 mmol Treat underlying cause of DKA
National protocol for DKA Care Pathway 1 (0-4 hours) To improve the acute management of diabetic ketoacidosis in adults aged 16 years and over within the first 4 hours of presentation
National protocol for DKA Care Pathway 2 (4 hours discharge) To improve management of diabetic ketoacidosis in adults aged 16 years and over more than 4 hours after presentation
Immediate actions Confirm DKA on venous gas Check U&Es and formal lab glucose Dipstick urine for ketones Ensure patient over 16 years Record time protocol started
Management 0-60 mins Commence 1l IV Sodium Chloride 0.9% over 1 hour Commence sliding scale insulin at 6ml/hr Time & date commencement of above Record BM / NEWS score
Other considerations Record GCS Consider cardiac monitor Consider Central line if poor venous access MSSU BC s DVT prophylaxis
Management to 1-4 hours Continue to monitor BM / NEWS 1 hourly Continue fluid rescuscitation 2nd hour 1l IV Sodium Chloride 0.9% over 1 hour 3rd hour IV Sodium Chloride 0.9% at 500ml/hr 4th hour IV Sodium Chloride 0.9% at 500 ml/hr Repeat U&Es, Lab Glucose & Bicarb at 2hrs & 4hrs Consider addition of K+ to IV fluids
Potassium replacement Hypokalaemia / hyperkalaemia are life threatening conditions and are common in DKA. Serum potassium is often high on admission (although total body potassium is low) but falls quickly upon treatment with insulin. Regular monitoring is required Potassium (K+) should not normally be administered at a rate of greater than 20mmol/hour
If BM falls to < 14 mmol/l within 4 hrs Commence 10% Glucose with 20 mmol K+ Promotes clearance of ketones Continue Sodium Chloride at reduced rate Reduce insulin rate to 3ml/hr Aim to maintain BM > 9 mmol/l and < 14mmol/L Progress to Care Pathway Part 2!
Care Pathway 2 Review 4hrly bloods Continue IV Sodium Chloride 0.9% at 250ml/hr until BM < 14 mmol/l then reduce to 150ml/hr Commence IV 10% Dextrose with 20mmol K+ (If not) Aim to maintain BG > 9 mmol/l and < 14 mmol/l Aim to reduce BG by 3 mmol/hr and increase Bicarb by 3 mmol/hr
Continual management Measure and record U&Es, lab glucose and Bicarb 4hrly for 24 hrs Continue IV fluids as prescribed If BM rises to > 14mmol/L do not stop IV Dextrose Give usual long acting insulin SC along with IV insulin if relevant. If no improvement or any concerns with your patient contact medical staff
Continual management Can consider discontinuing sliding scale when 1 Bicarb normal 2 Patient eating and drinking normally At this time give normal SC insulin at next convenient meal time Then stop IV fluids & IV insulin 30 mins after SC insulin given Refer onto Diabetic Specialist Nurses
Post acute phase If new diagnosis Type 1 DM refer to Diabetes Team Education and insulin initiation If known Type 1 / Type 2 DM Discuss potential cause and how to prevent Education sick day rules DSN / Dietitian follow up
Hyperglycaemic Hyperosmolar State (HHS)
What is Hyperglycaemic Hyperosmolar State (HHS)? o Generally occurs in elderly patients with Type 2 Diabetes o Severe hyperglycaemia (BG > 30mmol/l) o Total osmolality >340 Osm/kg o Serum bicarbonate > 15 mmol/l (not acidotic) o Urinary ketones < + plus
Symptoms of HHS Polyuria Polydipsia Nausea Dry skin Disorientation Drowsiness
Consider causes of HHS Common causes include Sepsis Medications steroids, ACE Diuretics Glucose rich drinks Pancreatitis New diagnosis Diabetes
Immediate actions Check a venous gas Check U&Es and formal lab glucose Check Osmolality MSSU BC s DVT prophylaxis
Management IV fluids & IV insulin Commence 1l IV Sodium Chloride 0.9% over 1 hour Further IV fluids given more cautiously than for DKA When BG falls <14 mmol/l add in 10% Dextrose at 100ml/hr Consider addition of K+ to IV fluids Commence sliding scale insulin at 6ml/hr Again aim for BG between 9-149 mmol/l Aim fall in BG 2-32 3 mmol/hr If fall too rapid reduce to 3ml/hr
Continual Management Can consider discontinuing sliding scale when 1. Normal biochemistry restored 2. When eating & drinking normally Recommence insulin or OHAs in patients previously treated Patients previously undiagnosed may require OHAs Refer to Diabetes Specialist Nurses
Post Acute Phase If new diagnosis Type 2 DM Refer to Diabetes Team Education Diet only / OHA initiation If known Type 2 DM Education DSN / Dietitan follow up?cdsn
Useful Links Diabetes UK - Diabetes.org.uk Diabetes in Scotland Diabetesinscotland.org.uk Association of British Clinical Diabetologists abcd.care Learn pro modules