diabetes & endocrine encounters

Diabetes & Endocrine encounters

Dr Raj Tanday

Consultant Endocrinologist

King George Hospital London

Objectives

• To be aware of management of diabetes emergencies - hypo/hyperglycaemia, DKA, HHS

• To understand causes, symptoms and management of common electrolyte emergencies – sodium, potassium, calcium

• To be aware of hypoadrenalism in emergency setting and its management

Diabetes

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 patient

• 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 hyperglycaemic state– B Diabetic ketoacidosis– C Sub optimally controlled diabetes– D Hypoglycaemia– E None of the above


• 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 hyperglycaemic 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


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 unless high risk of bleeding

Will need insulin long term Insulin/oral agents long term


Hyperosmolar states with ketoacidosis do exist so the term HONK is no longer used


• If no HHS or DKA likely suboptimallycontrolled diabetes

• Review overall trend and see what’s needed

• Try to avoid stat actrapids but if need tight control, symptomatic or >25

Any questions?

Electrolytes


• 70yr man • Admitted with SOB and leg swelling• PMH CCF EF 25%, type 2 diabetes • DH Frusemide 80mg od, linagliptin 5mg od• O/E JVP to earlobe, dull R base, pitting oedema, ascites, BP 110/65,

P95, Sats 90%air, afeb, BM 9• Na 120, 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


• 70yr man • Admitted with SOB and leg swelling• PMH CCF EF 25%, type 2 diabetes • DH Frusemide 80mg od, linagliptin 5mg od• O/E JVP to earlobe, dull R base, pitting oedema BP 110/65, P95,

Sats 90%air, afeb• Na 120, 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 – HyponatraemiaNa <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 +/- furosemide

• If euvolaemic – fluid restrict

• If unsure whether euvolaemic or dehydrated – trial slow iv N saline and see

Electrolytes - Hyponatraemia

• Send paired osmolarity, cortisol, TFT

• Aim to correct by 8-10 mmol/l in 24hrs

• If hyponatraemia is chronic faster correction can cause osmotic demyelination injury


• 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


• 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 – HypernatraemiaNa >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 – HypokalaemiaK <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 – HyperkalaemiaK >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 6.5mmol/l or 6.0mmol/l with ECG changes


• 75 yr old man

• Admitted with pneumonia

• PMH - hypertension

• DH - omeprazole, amiloride, ramipril

• Lab calls with K 6.4, Na 134, Ur 12, Creat 80

• Pt feels well

• RR 18, P 100 reg, BP 142/75, T 37.0, GCS 15

What would you do next?

• A ABG

• B Urinary catheter insertion

• C ECG

• D PR examination

• E Urine dip

• If K > 6.5 / K > 6.0 with ECG changes - needs acute treatment- Stop precipitating drugs– 100ml 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 – HypocalcaemiaCCa <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 – HypocalcaemiaCCa <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 alfacalcidolat 0.25 mcg per day

Electrolytes – HypercalcaemiaCCa >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

Any questions?


• 25 year old man• Admitted with 4 dizzy spells & vague abdominal

pain• PMH – primary hypothyroidism • DH – levothyroxine 100mcg od• SR – darkening of skin, loose stool• Obs - RR 23, Sats 98% OA, P 100, BP 90/65, GCS

15, BM 3.0• Blood tests –Na 124, K 5.8, Urea 12, Cr 70, WCC

5.0, CRP <5, TSH 1.10

What should be given next?

• A Inotropes

• B Steroids

• C Ng feeding

• D Antibiotics

• E Nothing further

What should be given next?

• A Inotropes

• B Steroids

• C Ng feeding

• D Alternative antibiotics

• E Nothing – your shift has ended

Adrenal insufficiency

• Primary adrenal failure – loss of function due to autoimmune/infiltration damage to cortex

• Secondary adrenal failure – loss of stimulation from pituitary

• In adrenal crisis give N saline and iv/im hydrocortisone 50-100mg qds. Do not wait for a cortisol level - if suspected treat!

• Be wary of sick patients who have been on long term steroid -they often require iv/im hydrocortisone or an increase of their oral dose

• Pituitary regulation of cortisol production is switched off in patients who receive chronic exogenous glucocorticoid treatment with doses ≥5 mg prednisolone equivalent for more than 4 weeks. This may also be caused by long-lasting glucocorticoid injections into joints or chronic application of glucocorticoid cream or inhalers.

And so – in summary


• Diabetes

– If hypo treat depending on symptoms

– If hyper exclude DKA & HHS. Rv trend & escalate medication. Consider stat actrapid if >25


• Diabetes – If hypo treat depending on symptoms


• Electrolytes– Na, K, Ca

– Hyponatraemia requires thought. Care with correction


• Diabetes – If hypo treat depending on symptoms


• Electrolytes– Na, K, Ca

– Hyponatraemia requires thought. Care with correction

• Adrenal crisis– If suspected treat

– Be wary of those who are sick on long term steroid

– Give saline & Iv/im hydrocortisone 50-100mg qds

Lastly

• There will be local trust protocols for acute management

• Don’t be afraid to ask SHO / SPR for advice

• Best wishes

diabetes & endocrine encounters

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