Diabetes & Endocrine Encounters The Sugary & Salty
Transcript of Diabetes & Endocrine Encounters The Sugary & Salty
Diabetes & Endocrine Encounters – The Sugary & Salty
Dr Raj Tanday
Consultant Endocrinologist
King George Hospital, London
Objectives
• Be able to manage diabetes mellitus related emergencies - hypo/hyperglycaemia, DKA, HHS
• To understand causes, symptoms and management of common electrolyte emergencies – sodium, potassium, calcium
Hypoglycaemia & Hyperglycaemia
Diabetes – Hypoglycaemia (glucose <4.0mmol/l)
• Asymptomatic or neuroglycopenic symptoms
• Causes
– SU/insulin therapy
– Liver impairment
– Hypoadrenalism
– Insulinoma
Diabetes – Hypoglycaemia
• Initial management – If able to swallow - 15-20g fast acting CHO either
• 90-120ml Lucozade or • 3 teaspoons dextrose powder or • 1 to 2 tubes of glucogel. Test glucose after 15 mins
– If unable to swallow either • 100ml 20% glucose over 15 mins or • 1mg glucagon im
Diabetes – Hypoglycaemia
• Once glucose is above 4 give 20g long acting CHO either
– meal
– 2 biscuits
– slice of bread
If on insulin don’t omit next dose
Needs rv of overall trend / adjustment of regime
Asked to see pt on call
• BM 23 • Known COPD and T2 diabetes on insulin • Urine dip shows ketones 1+ • pH 7.25, PCo2 10, PO2 9.4, HCO3 32 • Lab glucose 20, Na 130, K =5, Urea 5
• Is this
– A Hyperosmolar hyperglycemic state – B Diabetic ketoacidosis – C Suboptimally controlled diabetes – D Hypoglycaemia – E None of the above
Asked to see pt on call
• BM 23 • Known COPD and T2 diabetes on insulin • Urine dip shows ketones 1+ • pH 7.25, PCo2 10, PO2 9.4, HCO3 32 • Lab glucose 20, Na 130, K =5, Urea 5
• Is this
– A Hyperosmolar hyperglycemic state – B Diabetic ketoacidosis – C Suboptimally controlled diabetes – D Hypoglycaemia – E None of the above
Diabetes - Hyperglycaemia
• Hyperglycaemia - exclude DKA & HHS
– DKA
• Suspect if heavy ketosis ie >2+ on urine dip or > 1 on blood ketone
• Metabolic acidosis with pH <7.35
– HHS
• Need serum osmolality to be >320mOsm/l 2(Na+K) + urea + glucose
Diabetes - Hyperglycaemia
DKA HHS
Tend to be younger Tend to be older
Onset acute Onset insidious
Tend to be Type 1/ ketosis prone type 2 diabetics
Tend to be type 2 diabetics
Ketosis present Ketosis usually minimal or absent
Aggressive iv fluids Gentle iv fluids
Larger amount of iv insulin Smaller amounts eg 1 unit /hr
Prophylactic anticoag with LMWH Treatment dose anticoag with LMWH
Will need insulin long term Insulin/oral agents long term
Diabetes - Hyperglycaemia
Hyperosmolar states with ketoacidosis do exist so the term HONK is no longer used
Diabetes - Hyperglycaemia
• If no HHS or DKA likely just poorly controlled diabetes
• Review overall trend and see what’s needed
• Try to avoid stat actrapids but if >25 can give
Electrolytes
Asked to see pt on call
• 70yr man • Admitted with SOB and leg swelling • PMH CCF EF 25%, type 2 diabetes • DH Frusemide 80mg od, novomix 30 insulin 20Units bd • O/E JVP to earlobe, dull R base, pitting oedema, ascites, BP 110/65,
P95, Sats 90%air, afeb, BM 9 • Na 122, K 4.1, Cr 120, Ur 11 (baseline Na 128-132 in last yr) • How will you manage his Na?
– A Slow iv N saline – B Slow iv 5% dextrose – C Stop frusemide – D Fluid restrict – E Fluid restrict & increase frusemide
Asked to see pt on call
• 70yr man • Admitted with SOB and leg swelling • PMH CCF EF 25%, type 2 diabetes • DH Frusemide 80mg od, novomix 30 insulin 20Units bd • O/E JVP to earlobe, dull R base, pitting oedema BP 110/65, P95,
Sats 90%air, afeb • Na 122, K 4.1, Cr 120, Ur 11 (baseline Na 128-132 in last yr) • How will you manage his Na?
– A Slow iv N saline – B Slow iv 5% dextrose – C Stop frusemide – D Fluid restrict – E Fluid restrict & increase frusemide
Electrolytes – Hyponatraemia Na <133mmol (NR 133-146)
• Nausea, vomiting, lethargy, muscle weakness, seizures
• Causes - dehydration, failure states, hypoadrenalism, hypothyroidism, siADH, facticious
• Management – Neurological state ?if obtunded/coma/fitting needs iv
hypertonic saline
– If OK decide on fluid state • Dehydration – give iv N saline
• If overloaded ‘failure states’ – fluid restrict +/- frusemide
• If euvolaemic – fluid restrict
• If unsure whether euvolaemic or dehydrated – trial slow iv N saline and see
Electrolytes - Hyponatraemia
• Measure VBG Na 2 to 4 hrly
• Aim to correct by 8-10 mmol/l in 24hrs
• If hyponatraemia is chronic faster correction can cause osmotic demyelination injury
Electrolytes - Hyponatraemia
• SiADH – euvolaemic, normal renal, adrenal, thyroid function
• Urinary osmolality inappropriately high for serum (>100 mOsm/l). Urinary Na >30mmol/l
• Treat with fluid restriction
• Drugs can be used if restriction fails
Electrolytes - Hyponatraemia
• Urinary sodium is a useful test if not on diuretics
• Low <30 in failure states and dehydration
• High >30 in siADH and salt losing nephropathies
Electrolytes – Hypernatraemia Na >146mmol/l (NR 133-146)
• Lethargy, weakness, seizures, coma
• Is only caused by dehydration or diabetes insipidus
• ABC, slow 5 % dextrose
• Avoid rapid correction due to cerebral oedema
Electrolytes – Hypokalaemia K <3.5mmol/l (NR 3.5-5.3)
• Muscle weakness, cramps • ECG findings of inverted T waves, U waves • Causes
– GI loss – d&v, pancreatic fistulae – Urinary loss – diuretics, Conns, Cushings, Gittelmans,
Barters
• Management – Reduce losses – Stop offending drugs – Supplement
• Orally – sando K if GI tract working • Iv – with saline/dextrose if GI tract not working or <3mmol/l
Electrolytes – Hyperkalaemia K >5.3 mmol/l (NR 3.5-5.3)
• Malaise, muscle weakness, cardiac arrhythmias, ECG changes
• Causes – Ineffective elimination
• Renal failure, drugs, Addisons
– Excessive release from cells • Rhabdomyolysis, burns, tumour lysis, blood transfusion
• Treatment – Stop offending medications – Treat if over 6 mmol/l
Electrolytes – Hyperkalaemia
• If K > 6 needs acute treatment
– 50ml of 20 percent dextrose with 10 units of actrapid over 30 mins. Recheck in 1 hour. This can be repeated if necessary
– 10ml 10% calcium gluconate over 10 minutes
– Salbutamol nebs
– Resins can be used if >6.5
– If still high the insulin/dextrose can be repeated
Electrolytes – Hypocalcaemia CCa <2.20mmol/l (NR 2.20 – 2.60)
• Perioral & digital paresthesia, tetany, carpopedal spasm, seizures, long QT
• Severe vit D deficiency, Mg deficiency, post parathyroidectomy, pancreatitis, rhabdomyolysis, post blood transfusion
• Mild hypocalcaemia (asymptomatic / >1.9mmol/l) – Sandocal , Calcichew D3, AdCal 2tablets bd
• Severe hypocalcaemia (<1.9 and or symptomatic) – 10-20ml 10% calcium gluconate in 50-100ml 5% dextrose iv over 10 minutes with ECG monitoring. This can be repeated until pt asymptomatic. Follow this with 100ml of 10% calcium gluconate in 1 L % dextrose and infuse at 50-100ml/hr.
Electrolytes – Hypocalcaemia CCa <2.20mmol/l (NR 2.20 – 2.60)
• Treat underlying cause
– For Vitamin D deficiency use 20,000 units colecalciferol weekly
– For Mg deficiency use 24 mmol/24 made up as 6g MgSo4 in 500ml N saline
– If post parathyroidectomy can start 1 alfacalcidol at 0.25 mcg per day
Electrolytes – Hypercalcaemia CCa >2.60mmol/l (NR 2.20 – 2.60)
• Polyuria, polydipsia, depression, fatigue, muscle weakness, abdominal pain, vomiting, constipation, pancreatitis, coma, short QT
• Causes are – PTH mediated (if normal of high PTH)
hyperparathyroidism
– Non PTH mediated (suppressed PTH) – malignancy, sarcoidosis, TB, drugs, prolonged immobilisation, thyrotoxicosis, FHH
Electrolytes - Hypercalcaemia
• Management
– Iv Hydration - 3L N saline in 24 hrs
– Iv Bisphosphonates
– Steroids for granulomatous disease
– Cinacalcet/parathyroid surgery for hyperparathyroidism
Summary
• Diabetes
– If hypo treat depending on symptoms
– If hyper exclude DKA & HHS. Rv trend & escalate medication. Consider stat actrapid if >25
• Electrolytes
– Na, K, Ca
– Hyponatraemia requires thought. Care with correction
Lastly
• There will be local trust protocols
• Don’t be afraid to ask SHO / SPR for advice
• Best wishes