Management of Management of Diabetic Diabetic

EmergenciesEmergencies

ObjectivesObjectives

Will have a better understanding of Will have a better understanding of the management of diabetic the management of diabetic emergencies.emergencies.

Will see the necessity for an insulin Will see the necessity for an insulin protocol. protocol.

DefinitionDefinition

Diabetes Mellitus is a metabolic Diabetes Mellitus is a metabolic disorder characterized by disorder characterized by hyperglycaemia due to an absolute hyperglycaemia due to an absolute or relative lack of insulin or to a or relative lack of insulin or to a cellular resistance to insulin. cellular resistance to insulin.

Definition of DKA & Definition of DKA & HHNKSHHNKS

Diabetic Ketoacidosis is a medical Diabetic Ketoacidosis is a medical emergency resulting from an absolute or emergency resulting from an absolute or a relative deficiency in insulin secretion a relative deficiency in insulin secretion and an increase in the counter-and an increase in the counter-regulatory hormones.regulatory hormones.

Hyperosmolar Hyperglycaemic Non-Hyperosmolar Hyperglycaemic Non-ketotic Syndrome is medical emergency ketotic Syndrome is medical emergency resulting from a relative deficiency in resulting from a relative deficiency in insulin secretion and an increase in the insulin secretion and an increase in the counter- regulatory hormones.counter- regulatory hormones.

Precipitating Factors of Precipitating Factors of DKA & HHNKSDKA & HHNKS

Infectious ProcessesInfectious Processes Vascular disordersVascular disorders Endocrine disordersEndocrine disorders Concurrent medicationsConcurrent medications

Pathogenesis of DKAPathogenesis of DKAEffects on Carbohydrate Effects on Carbohydrate

MetabolismMetabolism

Insulin lack

Decrease in glucose use

Hyperglycaemia

Glycosuria, osmotic diuresis

Water & Electrolytes

Dehydration

Haemoconcentration

Peripheral circulatory failure

Hypotension

Renal blood flow

Anuria

Coma & Death

Effects on Fat Effects on Fat MetabolismMetabolism

Insulin lack

Decrease glucose use

Lipogensis in depots

Moblization of depot fat

Lipemia

Ketogensis in Liver

Ketonaemia

Ketonuria

Loss of Na+

Effects on Protein Effects on Protein MetabolismMetabolism

Insulin Lack

Decrease in glucose use

Protein Catabolism

Aminoacidemia

Gluconeogenesis

Urinary Nitrogen

Cellular Dehydration

Loss of K+ from cells

Net loss of body K+

Signs & Symptoms of Signs & Symptoms of DKADKA

PolyuriaPolyuria PolyphagiaPolyphagia PolydipsiaPolydipsia Weight lossWeight loss FatigueFatigue Blurred visionBlurred vision TachycardiaTachycardia

Signs & Symptoms of Signs & Symptoms of DKA con’tDKA con’t

Hypotension & orthostatic Hypotension & orthostatic hypotensionhypotension

Decreased skin turgorDecreased skin turgor Cardiac arrhythmiaCardiac arrhythmia Deep rapid respirationsDeep rapid respirations Acetone odour to breatheAcetone odour to breathe Red, flushed faceRed, flushed face AnorexiaAnorexia

Signs & Symptoms of Signs & Symptoms of DKA con’tDKA con’t

Nausea & vomitingNausea & vomiting Abdominal painAbdominal pain Decreased mental statusDecreased mental status ComaComa HypothermiaHypothermia Leg crampsLeg cramps

Signs & Symptoms of Signs & Symptoms of HHNKSHHNKS

PolyuriaPolyuria PolyphagiaPolyphagia PolydipsiaPolydipsia Weight lossWeight loss FatigueFatigue Blurred visionBlurred vision TacycardiaTacycardia Orthostatic hypotensionOrthostatic hypotension

Signs & Symptoms of Signs & Symptoms of HHNKSHHNKS

Decreased skin turgorDecreased skin turgor Cardiac arrhythmiaCardiac arrhythmia Decreased mental statusDecreased mental status ComaComa HemiparesisHemiparesis SeizuresSeizures ThrombosisThrombosis HypothermiaHypothermia Leg crampsLeg cramps

Management of DKA & Management of DKA & HHNKSHHNKS

Aims:Aims: Reduce blood glucose by 2-3mmol/lReduce blood glucose by 2-3mmol/l Prevent re- occurrencePrevent re- occurrence

Treatment of DKA & Treatment of DKA & HHNKSHHNKS

Rx of DKA & HHNKS involves:Rx of DKA & HHNKS involves:

1.1. General measuresGeneral measures

2.2. Insulin treatmentInsulin treatment

3.3. Fluid & electrolyte replacementFluid & electrolyte replacement

DKA in Children & DKA in Children & AdolscentsAdolscents

Aim:Aim: Reduce Blood glucoseReduce Blood glucose Prevent re-occurrence Prevent re-occurrence

DKA in Children & DKA in Children & AdolscentsAdolscents

Treatment of DKA in ChildrenTreatment of DKA in Children General MeasuresGeneral Measures Insulin treatmentInsulin treatment Fluid & Electrolyte ReplacementFluid & Electrolyte Replacement

General MeasuresGeneral Measures

Clinical Assessment: Neurological Clinical Assessment: Neurological status, cardiac rate and respiratory rate.status, cardiac rate and respiratory rate.

Biological Assessment: Blood glucose, Biological Assessment: Blood glucose, Na+, K+ & CL- & HCO3.Na+, K+ & CL- & HCO3.

Instrumental: ECG & BP, CXR, blood & Instrumental: ECG & BP, CXR, blood & urine culturesurine cultures

Admission: Q3hrly haemogasanalysis, Admission: Q3hrly haemogasanalysis, creatinine blood level & blood beta-creatinine blood level & blood beta-hydroxybutyrate.hydroxybutyrate.

Fluid & Electrolyte Fluid & Electrolyte ReplacementReplacement

First hour: IV treatment (re-hydration First hour: IV treatment (re-hydration only) of 0.9% NaCL ( 5-8ml/kg/hr)only) of 0.9% NaCL ( 5-8ml/kg/hr)

22ndnd hour & Onwards ( complete re- hour & Onwards ( complete re-hydration)hydration)

0.9% NaCL & K+ ( Max 4L/m2 in 24hrs-0.9% NaCL & K+ ( Max 4L/m2 in 24hrs-36hrs)36hrs)

14kg-21kg (age 3-6yrs): 2200ml/m214kg-21kg (age 3-6yrs): 2200ml/m2 22kg-29kg (age 7-9yrs): 1800ml/m222kg-29kg (age 7-9yrs): 1800ml/m2 30kg-55kg ( age > 10yrs): 1500ml/m230kg-55kg ( age > 10yrs): 1500ml/m2NB If Na+ is > 150mEq/L give 0.45% NaCLNB If Na+ is > 150mEq/L give 0.45% NaCL

Fluid & Electrolyte Fluid & Electrolyte ReplacementReplacement

If patient is urinating give K+ 0.1-If patient is urinating give K+ 0.1-0.2mEq/Kg/hr. Should be divided 0.2mEq/Kg/hr. Should be divided into 50% KPO4 & 50% KCL. into 50% KPO4 & 50% KCL. NB NB Dose adjusted Q1hryly or 2hrly Dose adjusted Q1hryly or 2hrly depending on the level of depending on the level of kalemia & or on kalemia & or on electrocardiography.electrocardiography.

Insulin TreatmentInsulin Treatment

If blood glucose is >13.8mmol give If blood glucose is >13.8mmol give 0.1-0.075IU/kg/hr.0.1-0.075IU/kg/hr.

If blood glucose is < 13.8mmol give If blood glucose is < 13.8mmol give 0.05-0.025IU/kg/hr & 10% DW @ 0.05-0.025IU/kg/hr & 10% DW @ 1ml/kg/hr.1ml/kg/hr.

Acute ComplicationsAcute Complications

DeathDeath Cerebral oedemaCerebral oedema Vascular thrombosisVascular thrombosis InfectionsInfections

ReferencesReferences

Treatment of DKA in Children & Treatment of DKA in Children & Adolescents by Maurizio Vanelli, Adolescents by Maurizio Vanelli, Francesco Charelli. Acta Bio Medica Francesco Charelli. Acta Bio Medica 2003: 74; 59-68.2003: 74; 59-68.

The Nursing Clinics of North America The Nursing Clinics of North America by Laurie Quinn, June 2001.by Laurie Quinn, June 2001.

Lothian Diabetes Handbook.Lothian Diabetes Handbook. Oxford Nurses Medical DictionaryOxford Nurses Medical Dictionary Pediatric Diabetic Ketoacidosis by Wing Pediatric Diabetic Ketoacidosis by Wing

K. Fung. CMAJ Aug 19; 2003:168 K. Fung. CMAJ Aug 19; 2003:168