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Management of diabetes emergencies''
1. MANAGEMENT OF
HYPEROSMOLAR
HYPERGLYCEMIC STATE
Dr. MUSA E.
NEPHROLOGY UNIT
POST-CALL REVIEW
2. LEARNING OBJECTIVES
• Define Diabetes Mellitus
• Diagnose & differentiate common diabetic
emergencies
• Know red flags of diabetic emergencies
• Manage common diabetic emergencies
3. What is Diabetes Melitus?
Body does not make or properly use insulin:
– no insulin production
– insufficient insulin production
– resistance to insulin’s effects
No insulin to move glucose from blood into
cells:
– high blood glucose means:
s fuel loss. cells starve
s short and long-term complications
3
4. Acute Complications of Diabetes
(Diabetic Emergencies)
D ia b e te s
D ia b e tic K e to a c id o s is H y p e rg ly c e m ic H y p e ro s m o la r S ta te H y p o g ly c e m ia
H y p e rg ly c e m ia H y p e rg ly c e m ia
A c id o s is w ith a n io n g a p N o a c id o s is
E le c tro ly te D is tu rb a n c e s H y p e rn a tre m ia a n d o th e rs
5. HYPEROSMOLAR HYPERGLYCAEMIC
STATE (HHS)
This is a metabolic emergency in persons with
uncontrolled type 2 DM. It was previously called
hyperosmolar non-ketotic state (HONK).
Diagnosis: the following must be present
Severe hyperglycaemia ( plasma glucose
>>35mmol/l)
Altered mental status
Serum osmolarlity > 320 mosm/L (normal
270-290mosm/L)
6. Other findings which may be present include;
• ketonaemia/ketonuria – mild or absent.
• Anion gap – normal or slightly elevated.
• pH > 7.3
• serum HCO3 > 18 mmol/L
• -patients are older, presenting in middle or later life.
• -mortality may be as high as 35%
• Accounts for 35.3% of DM-related admissions in Kano1
• 1. Uloko AE et al. AACE Presentation, Houston, Texas. May 2009
7. Precipitating factors
-newly diagnosed type 2 DM
-consumption of glucose-rich fluids (eg Lucozade)
-discontinuation of drugs
-surgery
-concurrent medications- thiazide diuretics or steroids
-intercurrent illness- CVD, MI, pancreatitis, UTI,
respiratory tract infection etc.
8. Pathophysiology of DKA/HHS
Insulin Deficiency
Increased Lipolysis Hyperglycemia
Increased ketogenesis Osmotic Diuresis
Ketoacidosis Hyperosmolality
Pure Diabetic Ketoacidosis Pure Hyperosmolar State
9. Presentation
-insidious onset with symptoms progressing over 1 week or more
-polyuria
-polydipsia
-severe dehydration (8 – 12litres)
-confusion, seizures
-stupor or coma in up to 20% of cases
-evidence of underlying illness eg UTI, pneumonia etc
-stroke, MI, or peripheral arterial disease in the lower limbs due to
hyperosmolality
10. Management
Principles
Rehydration
Correction of hyperglycaemia using insulin
Correction of electrolyte imbalance especially
potassium.
Treatment of underlying cause/precipitant
Prevention of complication
11. General measures
Same as for DKA
Calculate serum osmolality based on the formular:
Serum osmolality = [2(Na+ + K+) + plasma glucose + Urea]
mosm/L.
Fluid replacement;
-normal saline is the fluid of choice
-fluid replacement regimen as in DKA.
12. Insulin replacement
-similar to DKA with the following exceptions:
1. use ½ the dose of soluble insulin as in DKA
2. double the dose of insulin if no appreciable fall in
plasma glucose at a rate of 3mmol/l/hr after 3
hours of starting treatment.
3. commence insulin therapy only after
rehydration has started.
13. Correction of electrolyte inbalance
Treatment of precipitating cause;
-broad spectrum antibiotics if infection is suspected
-treat for MI, CVD, if indicated.
Prevention of complications;
-prophylactic anticoagulant is compelling because of
the high tendency of thrombo-embolic events.
-give subcut Heparin 5000 U 12Hourly (if no absolute
contra-indications). OR
-subcut Enoxaparin 40mg 12Hourly. Do baseline
clotting profile and INR monitoring especially if using
Heparin.
Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy by moving glucose from blood into the cells. People with diabetes have increased blood glucose (sugar) levels for one or more of the following three reasons: Either No insulin is being produced, Insulin production is insufficient, and/or The body is resistant to the effects of insulin. As a result, high levels of glucose build up in the blood, and spill into the urine and out of the body. The body loses its main source of fuel and cells are deprived of glucose, a needed source of energy. High blood glucose levels may result in short and long term complications over time.
Maintaining good blood glucose control is a constant juggling act, 24 hours a day, 7 days a week. The key to optimal diabetes control is a careful balance or juggling of food, exercise, and insulin and/or oral medication. As a general rule, insulin/oral medication and exercise/activity makes blood glucose levels go down. Food makes blood glucose levels go up. Several other factors, such as stress, illness or injury, also can affect blood glucose levels.