EMERGENCIES IN DIABETES

R Bowo Pramono PERKENI CABANG YOGYAKARTA

CV: dr. R Bowo Pramono SpPD K-EMD

Lahir

TEGAL 27-jan 1959 Istri: dr. Astuti, SpS, 2 putri Dokter Umum: FK UGM 17-01-1985 SpPD : FK UGM 24-11-1997 K-EMD : 14-05-2008 Pekerjaan: 1987-2002 PKM Kedung Waringin Bekasi 1999-2004 RSU Selong Lombok Timur 2004-2011 RS DR Sardjito/FK UGM
2

DISCUSSION

HYPOGLYCEMIA HYPERGLYCEMIC HYPEROSMOLAR STATE DIABETIC KETOACIDOSIS

HYPOGLYCEMIA

Hypoglycemia is a blood glucose value of less than 50 mg/dl Clinically, it is defined by Whipple triad: low plasma glucose level, symptoms consistent with hypoglycemia, and resolution of symptoms with correction of plasma glucose

Epidemiology

30% of type 1 or type 2 diabetic patients on insulin therapy 10% of type 2 diabetic patients Mortality rate 3-4% especially elderly taking long acting oral hypoglycemic agents

Symptoms
Adrenergic symptoms (catecholamine mediated): diaphoresis, palpitations, pallor, tachycardia apprehension, anxiety, sensation of hunger headache, weakness, restlessness
Neuroglycopenic symptoms: reduced intellectual capacity, irritability, confusion, abnormal behavior, convulsion, coma

Glucoregulatory factors

Blood-glucose-lowering factor

Blood-glucose-raising factors Glucose-counterregulatory factors

Insulin

Glucagon Epinephrine Growth hormone Cortisol

in minutes In hours

Physiologic response in hypoglycemia

Blood glucose 56-48 mg/dl * adrenalin secretion * diaphoresis, tremor * reduced function of central nervous system Blood glucose <48-36 mg/dl * reduced consciousness Blood glucose <36-18 mg/dl * coma, convulsion Blood glucose <18 mg/dl * permanent brain damage

Syndromes of compromised glucose counterregulation in type 1 diabetes mellitus

Defective glucose counterregulation Impaired awareness of hypoglycemia Elevated glycemic threshold during intensive therapy Elevated glycemic threshold following recent hypoglycemia Elevated glycemic threshold during -adrenergic blockade

Autonomic failure
The syndromes may occur in advanced type 2 diabetes mellitus (insulin-deficient)

Risk factors

Tight glycemic control Age Duration of diabetes History of hypoglycemia Sleeping Alcoholism Fasting Increased insulin sensitivity: fitness, body weight Clearance/metabolism of drugs: renal or hepatic insufficiency

Mechanisms by which drugs increase the hypoglycemic effect of sulfonilureas

Increase in half-life due to inhibition of metabolism or excretion rate: ethanol, phenylbutazone, coumarin anticoagulants, chloramphenicol, doxycycline, sulfonamides, allopurinol

Competition for albumin-binding sites: phenylbutazone, salicylates, sulfonamides

Inhibition of gluconeogenesis, increase in glucose oxidation, or stimulation of insulin secretion: ethanol, -adrenergic drugs, monoamine oxidase inhibitors, tranylcypromine,

Management of hypoglycemia

Mild hypoglycemia when self treatment with oral carbohydrate suffices Sever hypoglycemia when external help is required to effect recovery

Management of hypoglycemia: Prevention

1. 2. 3. 4.

5.

Early familiarization with the symptoms of hypoglycemia Do reviewing at intervals Explain the relationship between insulin administration, timing of meals, and exercise Explain methods of self-treating hypoglycemia Choose appropriate insulin regimens, dose schedules with appropriate therapeutic goals

Management of hypoglycemia: Treatment

Mild hypoglycemia: oral glucose 15-20 g, wait 10-15 min then check blood glucose. If glucose level does not increase 18 mg/dl, give oral glucose again Severe hypoglycemia: solution 50 ml of dextrose 50% given intravenously, check blood glucose in 20 min. If it is still hypoglycemia administrate once again Glucagon 1.0 mg s.c/i.m/i.v. adverse effects include nausea, vomiting, and headache. Contraindicated to sulfonylureas-induced hypoglycemia. Ineffective in patient who is anorectic, or with protracted hypoglycemia

DIABETIC KETOACIDOSIS

AND
HYPERGLYCEMIC HYPEROSMOLAR STATE

Pathophysiology of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)

laktic acid

DKA (DIABETIC KETOACIDOSIS)

Occurs when muscle cells become so starved for energy that body takes emergency measures & breaks down fat toxic acids as ketones Most common type 1 DM insufficient insulin to adjust raise of blood sugar Cause by extreme stress or illness Infection body produce adrenalin works against insulin Forget to take insulin

Signs & symptoms of DKA

Deep, rapid breathing Sweet, fruity smell on breath Loss of appetite Nausea Fatigue Vomiting Weakness Fever Confusion Stomach pain Drowsiness Weight loss

Clinical presentation

Lost more than 5% body weight More than 35 breaths a minute Cant control blood sugar Become confused Nausea and vomiting

What should you do?

Check ketones if feeling especially stressed or blood sugar persistently above 240mg/dL High ketones in blood ketones excreted in urine. High ketones in urine should be treated & n hospitalized DKA can lead into coma and possibly death.

Treatment

Correcting lost fluids through i.v. line Glucose infusion with insulin may stop ketones production Decrease blood sugar level gradually, decreasing glucose rapidly may produce brain swelling

Algorithm I.v. Insulin Infusion Therapy

BG (mg/dL) Insulin infusion dose (u/hr) Algr1 Algr2 Algr3 Algr4

< 60 = Hypoglycemia (need dextrose Tx) 60-70 0 0 0 0 70-109 0,2 0,5 1 1,5 110-119 0,5 1 2 3 120-149 1 1,5 3 5 150-179 1,5 2 4 7 180-209 2 3 5 9 210-239 2 4 6 12 240-269 3 5 8 16 270-299 3 6 10 20 300-329 4 7 12 24 330-359 4 8 14 28 >360 6 12 16 28

HHS (HYPERGLYCEMIC HYPEROSMOLAR STATE)

A high level of blood glucose may interfere blood circulation (level >600 mg/dl) Glucose uptake by the cells decreases, the glucose passed from blood to urine draws tremendous amounts of fluid from body and produces dehydration Common in type 2 DM, especially who does not monitor blood sugar, and who does not know have DM Trigger factors: high-dose steroid, diuretics, infection, illness, stress or drinking excessive alcohol

HHS: signs & symptoms

Excessive thirst Increased urination Weakness Leg cramps Confusion Rapid pulse Convulsions Coma

What should you do?

Check blood glucose level (> 600mg/dL) Emergency treatment can correct the problem within hours Give intravenous fluids to restore water to the tissue Short acting insulin to help cells can uptake glucose Without prompt treatment can be fatal