emergencies in diabetes

7/30/2019 Emergencies in Diabetes.

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EMERGENCIES IN DIABETES

R Bowo Pramono

PERKENI CABANG YOGYAKARTA


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CV: dr. R Bowo Pramono SpPD K-EMD

Lahir TEGAL 27-jan 1959 Istri: dr. Astuti, SpS, 2 putriDokter Umum: FK UGM 17-01-1985SpPD : FK UGM 24-11-1997K-EMD : 14-05-2008Pekerjaan: 1987-2002 PKM Kedung Waringin Bekasi 1999-2004 RSU Selong Lombok Timur 2004-2011 RS DR Sardjito/FK UGM

2


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DISCUSSION

HYPOGLYCEMIA

HYPERGLYCEMIC HYPEROSMOLARSTATE

DIABETIC KETOACIDOSIS


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HYPOGLYCEMIA Hypoglycemia is a blood glucose value of less

than 50 mg/dl

Clinically, it is defined by Whipple triad: lowplasma glucose level, symptoms consistentwith hypoglycemia, and resolution ofsymptoms with correction of plasma glucose


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Epidemiology 30% of type 1 or type 2 diabetic patients on

insulin therapy

10% of type 2 diabetic patients

Mortality rate 3-4% especially elderly takinglong acting oral hypoglycemic agents


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Symptoms

Adrenergic symptoms (catecholamine mediated):diaphoresis, palpitations, pallor, tachycardiaapprehension, anxiety, sensation of hunger

headache, weakness,restlessness

Neuroglycopenic symptoms:reduced intellectual capacity, irritability,confusion, abnormal behavior,convulsion, coma


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Glucoregulatory factors

Blood-glucose-loweringfactor

Blood-glucose-raisingfactors

Insulin

Glucose-counterregulatoryfactors

Glucagon

Epinephrine

Growth hormoneCortisol

in minutes

In hours


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Physiologic response in hypoglycemia

Blood glucose 56-48 mg/dl* adrenalin secretion

* diaphoresis, tremor

* reduced function of central nervous system Blood glucose


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Syndromes of compromised glucosecounterregulation in type 1 diabetes mellitus

Defective glucose counterregulation

Impaired awareness of hypoglycemia

Elevated glycemic threshold during intensive therapy

Elevated glycemic threshold following recenthypoglycemia

Elevated glycemic threshold during-adrenergicblockade

The syndromes may occur in advanced type 2 diabetes mellitus(insulin-deficient)

Autonomic failure


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Risk factors

Tight glycemic control

Age

Duration of diabetes

History of hypoglycemia Sleeping

Alcoholism

Fasting

Increased insulin sensitivity: fitness, body weight

Clearance/metabolism of drugs: renal or hepaticinsufficiency


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Mechanisms by which drugs increase thehypoglycemic effect of sulfonilureas

Increase in half-life due to inhibition of metabolism orexcretion rate:ethanol, phenylbutazone, coumarin anticoagulants,chloramphenicol, doxycycline, sulfonamides,

allopurinol

Competition for albumin-binding sites:phenylbutazone, salicylates, sulfonamides

Inhibition of gluconeogenesis, increase in glucoseoxidation, or stimulation of insulin secretion:ethanol, -adrenergic drugs, monoamine oxidaseinhibitors, tranylcypromine,


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Management of hypoglycemia

Mild hypoglycemia when self treatment withoral carbohydrate suffices

Sever hypoglycemia when external help is

required to effect recovery


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Management of hypoglycemia: Prevention

1. Early familiarization with the symptoms ofhypoglycemia

2. Do reviewing at intervals

3. Explain the relationship between insulinadministration, timing of meals, and exercise

4. Explain methods of self-treating hypoglycemia

5. Choose appropriate insulin regimens, dose scheduleswith appropriate therapeutic goals


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Management of hypoglycemia: Treatment

Mild hypoglycemia: oral glucose 15-20 g, wait 10-15 minthen check blood glucose. If glucose level does notincrease 18 mg/dl, give oral glucose again

Severe hypoglycemia: solution 50 ml of dextrose 50%given intravenously, check blood glucose in 20 min. Ifit is still hypoglycemia administrate once again

Glucagon 1.0 mg s.c/i.m/i.v. adverse effects includenausea, vomiting, and headache. Contraindicated tosulfonylureas-induced hypoglycemia. Ineffective in

patient who is anorectic, or with protractedhypoglycemia


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DIABETIC KETOACIDOSIS

AND

HYPERGLYCEMIC HYPEROSMOLAR STATE


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Pathophysiology of diabetic ketoacidosis (DKA) andhyperglycemic hyperosmolar state (HHS)


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laktic acid


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DKA(DIABETIC KETOACIDOSIS)

Occurs when muscle cells become so starved forenergy that body takes emergency measures &breaks down fat toxic acids as ketones

Most common type 1 DM insufficient insulin to

adjust raise of blood sugar Cause by extreme stress or illness Infection body produce adrenalin works

against insulin

Forget to take insulin


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Signs & symptoms of DKA

Deep, rapid breathing

Sweet, fruity smell on breath

Loss of appetite

Nausea

Vomiting

Fever

Stomach painWeight loss

Fatigue

Weakness

Confusion

Drowsiness


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Clinical presentation

Lost more than 5% body weight

More than 35 breaths a minute

Cant control blood sugarBecome confused

Nausea and vomiting


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What should you do?

Check ketones if feeling especiallystressed or blood sugar persistently above240mg/dL

High ketones in blood ketones excretedin urine.

High ketones in urine should be treated & nhospitalized

DKA can lead into coma and possibly death.


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Treatment

Correcting lost fluids through i.v. line

Glucose infusion with insulin may stopketones production

Decrease blood sugar level gradually,decreasing glucose rapidly mayproduce brain swelling


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Al ith I I li I f i Th


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Algorithm I.v. Insulin Infusion Therapy

BG (mg/dL) Insulin infusion dose (u/hr)Algr1 Algr2 Algr3 Algr4

< 60 = Hypoglycemia (need dextrose Tx)60-70 0 0 0 070-109 0,2 0,5 1 1,5

110-119 0,5 1 2 3

120-149 1 1,5 3 5150-179 1,5 2 4 7180-209 2 3 5 9210-239 2 4 6 12240-269 3 5 8 16

270-299 3 6 10 20300-329 4 7 12 24330-359 4 8 14 28>360 6 12 16 28


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HHS (HYPERGLYCEMIC HYPEROSMOLAR STATE)

A high level of blood glucose may interfere bloodcirculation (level >600 mg/dl)

Glucose uptake by the cells decreases, the glucosepassed from blood to urine draws tremendousamounts of fluid from body and producesdehydration

Common in type 2 DM, especially who does notmonitor blood sugar, and who does not know have

DM Trigger factors: high-dose steroid, diuretics,

infection, illness, stress or drinking excessive alcohol


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HHS: signs & symptoms

Excessive thirst

Increased urination

Weakness

Leg cramps

Confusion

Rapid pulse

Convulsions Coma


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What should you do?

Check blood glucose level (> 600mg/dL) Emergency treatment can correct the

problem within hours

Give intravenous fluids to restore water tothe tissue

Short acting insulin to help cells can uptakeglucose

Without prompt treatment can be fatal


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