hypoglycemia kad hhs

7/31/2019 Hypoglycemia Kad Hhs

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HYPOGLYCEMIA,HYPEROSMOLAR HYPERGLYCAEMIC

STATE (HHS)

AND DIABETIC KETOACIDOSIS (DKA)

Adrian Yusdianto

Vika Cahyani Yoningsih

Najmulhadi B Mohd SahriNurul Hakimmah Bt Abd Manan


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Hypoglycaemia may be defined as a low bloodglucose level, usually ofless than 3.0 mmol/l

(


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Always check a stat capillary blood sugar on

ANY patient presenting with altered mental

state/seizures

Capillary blood sugar readings read lower than

venous readings

artificially lower readings inhypotension, hypothermia and oedema. Hence,

always confirm hypoglycaemia with a VENOUS

sample to the lab


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CAUSES

HEALTHY-APPEARING PX

Medications/

drugs

Intenseexercises

Insulinoma

ILL-APPEARING PX

Sepsis/shock Infection

Starvation,anorexia nervosa

Liver/cardiac/renalfailure

EndocrineNon-islet cell

tumour


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50%

Insulin/oralhypoglycaemic

agent (OHA)

Intentional/

accidental overdose

Excess dose, illtiming, wrong type

of insulin

Decreased ofclearance due to

renal failure


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Clinical Features

AUTONOMIC (BSL 2.8-3.0 mmol/l) Shaking

Trembling

Diaphoresis

Tachycardia Pallor

NEUROGLYCOPENIA (BSL


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Management

Low flowoxygen

Monitor : ECG,pulse oxymetry,

vital signs

Check capillaryblood glucose


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History

Check for diabetes mellitus, medication

history, recent change in drug doses, recent

and chronic illness.

If patient is unconscious, obtain history from

caregivers/family.


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INVESTIGATION

Venous blood glucose,

urea, electrolytes,

creatinine, liver function

tests, FBC

Non-diabetic draw 5-

10 ml blood sample for

serum insulin, C peptides

and cortisol prior to giving

treatment to help the in-patient team in the

subsequent endocrine

evaluation for patient.


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Treatment

Fully conscious patient

Oral therapy give a

carbohydrate rich drink (Eg

Milo, Horlicks, Ensure,orange juice) and feed the

patient.

Unconscious patient

IV Dextrose 50% 40-50ml

If IV access in unavailable/very

uncooperative patients, IM/SCglucagon 1mg may be given.

Chronic alcoholism IV

thiamine 100 mg

Adrenal insufficiency IV

hydrocortisone 100-200 mg

Injury tetanus prophylaxis


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Adult hypoglycemia treatment

by American Diabetic

Association


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The majority of patients

should recover in 20-30

minutes.

If there is a persistent

altered mental state

despite the resolution of

hypoglycaemia, other

pathology must be

considered, and a CT scanof the brain may be

indicated!


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HYPERGLYCAEMICEMERGENCIES


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Diagnostic Criteria

Diabetic Ketoacidosis (DKA)

Blood glucose >or equal to

14 mmol/l

Acidaemia with arterial pH7.3,

bicarbonate >15 mmol/l Absence of severe

ketonaemia/ketonuria

Serum total osmolality >330

mOsm/kg H2O OR serumeffective osmolality >320

mOsm/kg H2O


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Clinical Features

Polyuria,polydipsia,

nocturiaWeight loss Hyperventilation

Acetone breath Vomiting Abdominal pain

Hypotension Drowsiness Coma


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Causes

Infection

Infarction

Insufficientinsulin

Intercurrentillness


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Laboratory

FBC

Uea/electrolytes/creatinine/calcium/magnesiu

m/phosphate/serum

osmolality/ABGs/urinalysis

Monitoring ECG, pulse oxymetry, vital

signs, blood glucose and potassium every 1-2

hours

Urinary cathater to monitor urine output


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Management

I. Fluid Replacement (First hour)

Administer normal saline at 15-20 ml/kg/h in

the first hour, with recourse to colloids if

patients is still hypotensive.


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Management

Fluid Replacement (next 2-4 hours)

SerumNa

HIGH

0.45%

NaCl 10-20ml/kg/h

S

erumNaNO

RMAL

0.45%

NaCl 10-20ml/kg/hr

SerumNaLOW

0.9%

NaCl 10-20ml/kg/hr


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Management

II. Restoration of Electrolyte Balance

20-40 mEq KCl per hourSerum K

5 mmol/l


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Management

III. Restoration of Acid-Base Balance

pH 6.9-7.9

50 ml 8.4%NaHCO3,dilute in 200

ml NS and runover 1 hour

pH


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Management

IV. Insulin Administration

Bolus dose of0.15 units/kg BW

SI

Low dosecontinuous

infusion of 0.1units/kgBW/hour

Blood glucose


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hypoglycemia kad hhs

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