A lady with vomiting

A 23-year-old female student presents to her GP 5 days after returning from a ski holiday. She developed what she thought was a stomach upset while away, but this failed to settle and she now has increasing nausea and recurrent

vomiting.

Initial management

• Fingerprick blood glucose in GP surgery simply reads "high" on meter.

How would you manage her?

How would you manage her?

Investigations

• She has arrived in the emergency assessment unit and you are the first doctor to see her. You confirm the history as above and a nurse checks a fingerprick blood glucose for you which simply reads “high” on the meter. She looks unwell and is slightly drowsy and breathing rapidly.

What tests would you arrange and what might you expect to find?

What tests would you arrange and what might you expect to find?

• ABG

• UE

• Blood glucose

• CXR

• ECG

Initial treatment I

• Her tests confirm that she is acidotic (pH 7.03) and blood glucose is 46 mM.

How would you manage her now?

How would you manage her now?

• Fluids

• Insulin

• Potassium replacement as necessary

• Ng tube

• ?ITU

Initial treatment II

• After 12 hours of iv insulin and fluids, she looks and feels better. Her acidosis has resolved and her blood glucose has fallen to 8 mM.

What do you do now?

Next step

• After 48 hours of intravenous insulin, her urinary ketones have cleared completely and she is eating and drinking.

monitoring

Prescribing

• Sometimes when diabetic patients in hospital are unwell or are nil by mouth for medical procedures or operations, they are prescribed 'sliding scale' insulin.

Change over

• The medical team has decided that the patient is stable enough to be changed over to a sub-cutaneous insulin regime.

How long before stopping the insulin infusion should the first sub-cutaneous insulin dose be given?

She asks you about the long-term implications for her health of

developing diabetes.

Long term complications

large blood vessels

small blood vessels

TIA

stroke

angina

myocardial infarction

heart failure

peripheral vascular

disease

diabetic retinopathy

diabetic nephropathy

erectile dysfunction

autonomic neuropathy

peripheral neuropathy

Systems affected by diabetes

retinopathy

ischaemic heart disease

Diabetic Nephropathy

An insidious clinical syndrome characterised by persistent albuminuria, elevated blood

pressure and , if left untreated ,a relentless decline in GFR

What is diabetic nephropathy ?

20 40 12010060 80

Kidney

function

age

Kidney function and age

100%Diabetic kidney

disease

Detected and treated

trouble

GOOD NEWS

#1 onset and course of diabetic nephropathy

can be ameliorated to a very significant degree

by interventions

#2 these interventions have their greatest impact

if instituted early on in the course of the condition

- the condition is important

- there is treatment

- facilities for diagnosis/ treatment exist - there is a recognised early stage

- there is a suitable test

- the test is acceptable to the population

- interveniton is cost effective

#2 Screening

Lewis, E. J. et al. N Engl J Med 1993;329:1456-1462

ACE inhibitors and diabetic nephropathy

Cumulative incidence in patients with DN

What is glycosylated haemoglobin

betaalpha

haemoglobin

betaalpha

haemoglobin

betaalpha

haemoglobin

HbA1C

HbA1CHbA

HbA1C (%)

Average Blood Sugar (mmol/L)

5 4.5

6 6.7

7 8.3

8 10.0

9 11.6

10 13.3

11 15.0

12 16.7

DCCTThe Diabetes Control and Complications Trial

1993

Retinopathy in Patients with Type 1 DM Receiving Intensive or Conventional Therapy-

9.1%

7.2%