diabetes & endocrine encounters
TRANSCRIPT
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
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 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 unless high risk of bleeding
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 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
Asked to see patient
• 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
Asked to see patient
• 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
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 – 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
Asked to see patient
• 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
What would you do next?
• A ABG
• B Urinary catheter insertion
• C ECG
• D PR examination
• E Urine dip
ECG
• 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?
Asked to see patient
• 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
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
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
• Electrolytes– Na, K, Ca
– Hyponatraemia requires thought. Care with correction
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
• 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