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