Low to high sugars- What an Emergency Physician must know
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Emergencies due to low or high blood sugars
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Low to high sugars- What an Emergency Physician must know
- 1. Dr Soumar Dutta Consultant & Coordinator– Emergency Medicine Narayana Superspeciality Hospital, Guwahati LOW TO HIGH SUGARS - WHAT AN ED PHYSICIAN MUST KNOW
- 2. Glucose is an obligate metabolic fuel for the tissues under physiologic conditions INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic acute complications of diabetes. Its overtreatment – usually with insulin – leads to hypoglycemia Both hyperglycemic or hypoglycemic emergencies are associated with immediate and long-term adverse clinical outcomes and can be fatal if not recognized and treated timely. 60-150 mg/dl HyperglycemiaHypoglycemia
- 3. GLUCOSE HOMEOSTASIS Sources GI GlycogenolysisGluconeogenesis Lactate/Pyruvate Amino Acids Glycerol
- 5. DKA It is a serious acute metabolic complication of type 1 diabetes and ketosis-prone type 2 diabetes DKA Hyperglycemia KetonemiaMetabolic acidosis The biochemical diagnostic criteria for DKA are : •Ketonemia >3.0 mmol/L or significant ketonuria (more than 2+ on standard urine sticks) •Blood glucose >11 mmol/L or known diabetes mellitus •Bicarbonate (HCO3 −) <15 mmol/L and/or venous pH < 7.3
- 6. HHS It is a life-threatening emergency that, although less common than its counterpart, DKA, has a much higher mortality rate, reaching up to 5-10%. HHS was previously termed hyperosmolar hyperglycemic non-ketotic coma (HHNC); however, the terminology was changed because coma is found in fewer than 20% of patients with HHS HHS is most commonly seen in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake
- 7. CRITERIA FOR HHS Plasma glucose level of 600 mg/dL or greater Effective serum osmolality of 320 mOsm/kg or greater Profound dehydration, up to an average of 9L loss Serum pH greater than 7.30 Bicarbonate concentration greater than 15 mEq/L Small ketonuria and low to absent ketonemia Some alteration in consciousness
- 8. PATHOPHYSIOLOGY - DKA & HHS
- 9. DKA & HHS Mild Moderate Severe HHS Plasma Glucose (mg/dl) > 250 > 250 > 250 > 600 Arterial pH 7.25-7.30 7.00-7.24 < 7 > 7.30 Serum bi-carbonate(mEq/L)) 15-18 10-15 < 10 > 15 Urine Ketones Positive Positive Positive Small Serum Ketones Positive Positive Positive Small Effective osmolarity Variable Variable Variable > 320 AG > 10 > 12 > 12 < 12 Mental Status Alert Alert/Drowsy Stupor/Coma Stupor/Coma DKA
- 10. CAUSES LEADING TO DKA & HHS Omission or reduced daily insulin injections Infection Pregnancy Hyperthyroidism, pheochromocytoma, Cushing’s syndrome Substance abuse (cocaine) Medications: steroids, antipsychotics, sympathomimetics, thiazides Heat-related illness Cerebrovascular accident GI hemorrhage Myocardial infarction Pulmonary embolism Pancreatitis Major trauma Surgery
- 11. CASE SCENARIO - 01 E. IV Normal Saline D.IV Potassium C. IV Phosphates B. IV Lactated Ringers A. IV Bicarbonate A 37-year-old male presents to the ED with altered mental status. He was found unconscious at work. On examination, he is arousable to painful stimulus. His airway is intact and he has bilateral breath sounds. His initial vital signs are BP - 95/47, PR - 110, RR - 14, O2 % 97% on room air, Temp- 99.4. He has dry mucus membranes. Fingerstick glucose is 396 mg/dl. Lab work reveals a normal CBC, 3+ acetone, Na 121, Cl− 97, HCO3 - 9, K 3.0, Mg 2.9, Phos 1.5, AG 29. Which of the following is the first priority in caring for this patient?
- 12. E. IV Normal Saline DKA, it is very important to prioritize therapeutic interventions. The order of therapeutic priorities is volume resuscitation first and foremost, with the aim of: • Restore the circulatory (intravascular) volume • Improve tissue /renal perfusion • Correct hyperosmolality • Improves insulin sensitivity by reducing circulatory counterregulatory hormones. DKA HHS Water Deficit 100 ml/Kg 100-200ml/Kg Corrected [Na + ] = 1.6 × glucose (mg/dL) − 100 + [measured Na+] 100 2.4 , BG > 400 mg/dl
- 13. The goal is to replace half the estimated water deficit over a period of 24 hours Isotonic saline (0.9% NaCl) at a rate of 500 to 1000 mL/hour during the first 1 to 2 hours is usually sufficient to restore blood pressure and renal perfusion. Hemodynamics State of hydration Serum electrolyte levels Urinary output Once the plasma glucose is ∼250 mg/dL, 5% to 10% dextrose should be added to replacement fluids to allow continued insulin administration until ketonemia is controlled, while at the same time avoiding hypoglycemia. 0.45 %250- 500 ml/Hr..9 %
- 14. TYPICAL DEFICITS IN DKA AND HHS DKA HHS Sodium 7-10 mmol/kg 5-13 mmol/kg Phosphate 1 mmol/kg 3-7 mmol/Kg Potassium 3-5 mmol/kg 4-6 mmol/kg Chloride 3-5 mmol/kg 5-15 mmol/kg
- 15. POTASSIUM DEFICIT AND REPLACEMENT If initial [K+] >5.2 initiate IV infusion of regular insulin. Repeat [K+] in 2 hours. If initial [K+] is >3.3 and <5.2 add 20-30 mEq of [K+]to each liter of fluid and start insulin drip. If initial [K+] is < 3.3 hold insulin drip and give [K+] @ 20-30 mEq/h until [K+] is >3.3 then initiate insulin. Despite total body [K+] deficit there is spurious normal ~ high measured [K+] values Cells K + K + Acidemia Insulin Deficiency Hypertonicity
- 16. BICARBONATE REPLACEMENT HCO3 is not routinely recommended in DKA (pH > 7) Impaired myocardial contractility Cerebral vasodilation Coma pH < 6.9 50 to 100 mmol of sodium bicarbonate should be given as an isotonic solution (in 200 mL of water) every 2 hours until the pH rises to ∼6.9 to 7.0. In patients with arterial pH >7.0, no bicarbonate therapy is necessary
- 17. PHOSPHATE AND MAGNESIUM Correction usually not required Periodic Monitoring
- 19. 74-year-old woman who is a known diabetic is brought to the ED by EMS with altered mental status. The home health aide states that the patient ran out of her medications 4 days ago. Her BP is 130/85 mm Hg, HR is 110 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. On examination, she cannot follow commands but responds to stimuli. Laboratory results reveal normal CBC Na 128 mEq/L, K 3.0 mEq/L, Cl 95 mEq/L, Hco3 22 mEq/L, BUN 40 mg/dL, Cr 1.8 mg/dL, and glucose 850 mg/dL. Urinalysis shows 3+ glucose, 1+ protein, and no blood or ketones. After addressing the ABCs, which of the following is the most appropriate next step in management? A. Begin fluid resuscitation with a 2- to 3-L bolus of normal saline B. Begin fluid resuscitation with a 2- to 3-L bolus of normal saline; then administer 10 units of regular insulin intravenously and begin phenytoin for seizure prophylaxis. C. Administer 10 units of regular insulin intravenously; then begin fluid resuscitation with a 2- to 3-L bolus of normal saline. D. Order a computed tomographic (CT) scan of the brain; if negative for acute stroke, begin fluid resuscitation with a 2- to 3-L bolus of normal saline. E. Arrange for urgent hemodialysis.
- 21. COMPLICATIONS OF DKA AND HHS • Hypoglycemia • Hypokalemia • Cerebral Edema • AKI • Venous Thromboembolism • Rhabdomyolysis
- 22. A 47-year-old man presents with hypoglycemia. He is a known type 2 diabetic on glyburide. Fingerstick glucose is 27 mg/dL. Twenty minutes after two ampules (50 g) of dextrose, his glucose level is 29 mg/dL. Which of the following agents is indicated? Answer: E. A patient with hypoglycemia from sulfonylureas, in addition to standard glucose replacement, frequently requires treatment with an agent to inhibit further insulin release, such as octreotide (a somatostatin analogue). Sulfonylureas are insulin secretagogues. A. Adenosine B. Epinephrine C. Glucagon D. Hydrocortisone E. Octreotide
- 23. HYPOGLYCEMIA Glucose is an obligate metabolic fuel for all tissues under physiologic conditions Brain cannot synthesize glucose, store more than a few minutes’ supply as glycogen, or utilize physiologic concentrations of circulating fuels effectively. Clinical Hypoglycaemia Whipple Symptoms, signs, or both consistent with hypoglycemia. A low reliably measured plasma glucose concentration. Resolution of those symptoms and signs after the plasma glucose concentration is raised
- 24. HYPOGLYCAEMIA Neuroglycopenic symptoms are a direct result of brain glucose deprivation comaseizure psychomo tor abnormali ties behavioral changes cognitive impairme nts Sympathoadrenal Trigger by hypoglycemia
- 25. HYPOGLYCEMIA-ASSOCIATED AUTONOMIC FAILURE IN DIABETES
- 26. HYPOGLYCEMIA TREATMENT 15 – 20 Gm Sugar (PO, PR,IV) Pure fructose does not cross the blood–brain barrier 15-20 mins Glucagon, in a dose of 1.0 mg in adults, SC/IM Or 150 µg repeated if necessary Glycogen depleted
- 27. DISPOSITION
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Hinweis der Redaktion
- . The body's homeostatic mechanism of blood sugar regulation (known as glucose homeostasis), when operating normally, restores the blood sugar level to a narrow range of about 4.4 to 6.1 mmol/L (79 to 110 mg/dL) (as measured by a fasting blood glucose test).