hyperglycemia for dm educators march 2016
TRANSCRIPT
DIABETES MELLITUS
DKA & HHS
DR MOHAMMAD DAOUD CONSULTANT ENDOCRINOLOGIST KAMC -JEDDAH
CASE 1
A young patient Mom is calling you for advice
Her 13-yr old boy with Type 1 DM is having abdominal pain with N,V and diarrhea and refusing to eat
He is on Glargine 14 units bedtime and Aspart 6 units with each meal
Should I give him his insulin ? What else?
CASE 2
A 68 year old woman with DM Type 2 on Metformin 1g bd, Gliclazide 90 mg and Detemir 30 u
am
He has fever and shortness of breath for 4 days and since yesterday he is lethargic and sleepy
Also has polyuria and polydipsia
Your advice ?
OBJECTIVES
Introduction
Pathogenesis
Clinical Picture
Management ; Your Role
TYPE 1 VS TYPE 2
Type 1 DM
Immune system stops insulin from being
madeAlmost absent !!
All ages :More in younger
age groups
Type 2 DM
-Inadequate insulin/GLP1-Insulin resistance-Alpha cell :Glucagon more than needed-SGLT2 :excess glucose reabsorbed
Affects older age groupCan affect children
TYPE 1 VS TYPE 2
How is it treated?
Type 1 DM The insulin must be replaced
By injection or continuous infusion
Type 2 DM -Lifestyle changes (TLC)
-Medications : Tablets and/or
Injections ;Insulin / GLP! RA-Surgery !
ACUTE DIABETIC COMPLICATIONS
1-Hyperglycemia : High
-Diabetic Ketoacidosis (DKA)..Type 1 DM
-Hyperosmolar Hyperglycemia Syndrome (HHS) ..Old Type 2 DM
2-Hypoglycemia : Low
Amount of CHO loadPhysical activity
-Insulin …Lowers-Glucagon…Increases
-Other Pancreatic hormones : Amylin-Intestinal Hormones : GLP-1…
Stress factors Counter Regulatory Hormones
WHAT CONTROLS YOUR BLOOD SUGAR?
When we eat …blood sugar (Glucose) increases
This stimulates insulin secretion
Insulin moves the glucose out of the Blood Cells
WHAT CONTROLS YOUR BLOOD SUGAR?
GLUCOSE :FACTS
Carbohydrates (Glucose) are the main calorie source for our body
Extra CHO are stored as:
Glycogen (liver and muscles)OR
Fat (Adipose tissue)
GLUCOSE :FACTS
The brain relies almost exclusively on glucose as a fuel, but cannot
synthesize or store it
Adequate uptake of glucose from the plasma is essential for normal brain
function and survival
GLUCOSE PHYSIOLOGY
Glycogen Breakdown -
LiverIncreased Glucagon
Energy Fat Synthesis
Glycogen Synthesis
Glucose release to
blood (+) Pancreas secretion
of Glucagon Blood Glucose
Pool(+) Pancreas secretion of
Insulin
(+) Circulating Insulin Uptake of
glucose by cells
Decrease blood glucose
GLUCOSE :FACTSIn case of CHO shortage ( ex:
Starvation) OR
Unable to use CHO ( ex: No insulin as in DKA)
Body shifts gear to other sources of energy
GLUCOSE :FACTS
Other sources of energy …
Protein breakdown to amino acids
and glucose synthesis
Fat breakdown into FFA and ketones formation (with acidosis)..
Minimal amount of Insulin can prevent Ketogenesis
HYPERGLYCEMIA
Hyperglycemia basic processes are :
1-Impaired/decreased glucose use
2-Increased gluconeogenesis(Make up of glucose from other sources)
3-Increased glycogenolysis (breakdown of Glycogen to Glucose )
HYPERGLYCEMIA
Due to variable reasons…
Insulin deficiency (Absolute / Relative) Insulin Resistance
Excess counter regulatory hormones (Glucagon, Cortisol…)
Defected secretion of GLP-1…
Electrolyte LossesRenal Failure
Shock CV Collapse
INSULIN DEFICIENCY
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Hyperglycemia
Hyper-osmolality
Δ MS
CV Collapse
Glycosuria
Dehydration
Lipolysis
FFAs
Acidosis
Ketones
CV Collapse
INSULIN DEFICIENCY
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Electrolyte LossesRenal Failure
Shock CV Collapse
INSULIN DEFICIENCY
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Hyperglycemia
Hyper-osmolality
Δ MS
Lipolysis
FFAs
Acidosis
Ketones
CV Collapse
Glycosuria
Dehydration
DIABETIC HYPERGLYCEMIC CRISES
Diabetic Ketoacidosis(DKA)
Hyperglycemic Hyperosmolar State (HHS)
Younger, type 1 diabetes Older, type 2 diabetes
No hyperosmolality Hyperosmolality
Volume depletion Volume depletion
Electrolyte disturbances Electrolyte disturbances
Acidosis No acidosis
DIABETIC KETOACIDOSIS (DKA) PATHOPHYSIOLOGY
Unchecked gluconeogenesis Hyperglycemia
Osmotic diuresis Dehydration
Unchecked ketogenesis Ketosis
Dissociation of ketone bodies into hydrogen ion and anions Metabolic Acidosis
High Anion-gap
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Often a precipitating event is identified (infection, lack of insulin administration)
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS) PATHOPHYSIOLOGY
Unchecked gluconeogenesis Hyperglycemia
Osmotic diuresis Dehydration
• Presents commonly with renal failure
• Insufficient insulin for prevention of hyperglycemia but sufficient insulin for suppression of lipolysis and ketogenesis
• Absence of significant acidosis
• Often identifiable precipitating event (infection, MI)
Major body water loss DKA 5-7 L HHS 8- 10 L
HYPERGLYCEMIAPRECIPITATING FACTORS
Stress: Through excess counter regulatory hormones: -Glucagon -Catecholamines (Adrenaline and Nor-Adrenaline)-Cortisol
Medications: Steroids, Thiazides ,Beta blockers,… Stopping DM medications
Acute illness: Infections (ex;UTI, Pneumonia) ,MI (ACS), Stroke , Acute Pancreatitis, Burn
Others: Trauma ,Alcohol, Drug abuse (cocaine ) Feeding (NGT/ PEG/ TPN)
DKA -PRECIPITATING FACTORS Inadequate insulin treatment
Noncompliance Insulin error or insulin pump malfunction
Poor “sick-day” management
New onset diabetes (20 -25%)
Acute illness Infection ,CVA, MI ,Acute pancreatitis
Drugs: Steroids ,Clozapine or olanzapine
Cocaine Lithium ,Terbutaline
HHS -PRECIPITATING FACTORS
Acute illness : Infection : Pneumonia UTI, Sepsis
CVA, MI, Pancreatitis , PE, Severe burns…
Endocrine Acromegaly ,Thyrotoxicosis,
Cushing's syndrome
DrugsEx ;Steroids Thiazides,TPN
Previously undiagnosed DM
HYPERGLYCEMIAWHAT IS DKA?
Severe hyperglycemia ; 250-300 mg/dl
Ketonemia : ketone bodies in the blood(β-OH-butyric acid, Acetoacetic acid and
Acetone)
Acidosis: PH <7.3
= Lack of insulin
Hyperglycemia
Ketosis
Acidosis
Adapted from Kitabchi AE, Fisher JN. Diabetes Mellitus. In: Glew RA, Peters SP, ed. Clinical Studies in Medical Biochemistry. New York, NY: Oxford University Press; 1987:105.
DKA : DEFINITION
HYPERGLYCEMIADKA
Inadequate insulin & excess glucagon,catecholamines…
Body cannot burn glucose properlyGlucose builds up in the bloodstream
HYPERGLYCEMIADKA
Symptoms of DKA include:
Nausea, vomiting Abdomen/Stomach pain
Frequent urination Excessive thirst
Weakness, fatigue Speech problems
Confusion /Unconsciousness
HYPERGLYCEMIADKA
Signs of DKA include:Kussmaul respirations : Heavy, deep breathing
Fruity breath – the smell of ketoacid
TachycardiaSupine hypotension,
Orthostatic drop of BP (feel dizzy when standing)
Dry mucous membranes Poor skin turgor
Confusion /Unconsciousness
HYPERGLYCEMIADKA
Inadequate insulin …
Fat comes out of fat cells (Free Fatty Acids)….
In the liver (Mitochondria/ Glucagon)…
to be used as an alternative energy source
Makes ketoacids ( ketones) out of the fat
HYPERGLYCEMIAHHS
1- Severe hyperglycemia 2- S. Osmolality > 320 msom/kg
3- Severe dehydration 4- No ketonemia 5- No acidosis
HHS
There is just enough insulin
to keep fat in fat cells and prevent ketone /acids formation
ketone levels are usually normal in HHS.
Hyperglycemia
Hyperosmolarity
Ketoacidosis
HHSDK
A
Take Home Messages
HYPERGLYCEMIC CRISISDKA & HHS• LIFE THREATENING EMERGENCIES
• DKA …MOSTLY TYPE 1 –YOUNG INSULIN DEFICIENCY -ACIDOSIS • HHS….TYPE 2 DM –OLDER WORSE DEGREE OF DEHYDRATION • BOTH: SIMILAR PRECIPITATING
FACTORS ELECTROLYTES DISTURBANCES
DKA VS HHS
Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar State
(HHS)Absolute (or near-absolute) insulin deficiency, resulting in• Severe hyperglycemia• Ketone body production• Systemic acidosis
Severe relative insulin deficiency, resulting in• Profound hyperglycemia
and hyperosmolality (from urinary free water losses)
• No significant ketone production or acidosis
Develops over hours to 1-2 days
Develops over days to weeks
Most common in type 1 diabetes, but increasingly seen in type 2 diabetes
Typically presents in type 2 or previously unrecognized diabetesHigher mortality rate
DKA & HHS• EARLY AGGRESSIVE MANAGEMENT • HYDRATION • INSULIN • ELECTROLYTES DISTURBANCES RX• LOOK FOR PRECIPITATING FACTORS :
TREAT AND TEACH TO AVOID ..IF POSSIBLE
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PREDISCHARGE CHECKLIST• EDUCATION = PREVENTION• DIET INFORMATION• TREATMENT GOALS• “SURVIVAL SKILLS” TRAINING• “MEDIC-ALERT” BRACELET• PROVIDE : GLUCOSE MONITOR AND STRIPS MEDICATIONS, INSULIN, NEEDLES• CONTACT PHONE NUMBERS
TO PREVENT = EDUCATION • ADHERENCE /COMPLIANCE TO RX : BASAL INSULIN / CORRECTIVE DOSES …ETC
• SICK DAYS RULES
• RECOGNIZE CLINICAL PICTURE / SMBG
• SEEK MEDICAL CARE WHEN NEEDED40