Hyperglycemia for dm educators March 2016
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Transcript of Hyperglycemia for dm educators March 2016
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DIABETES MELLITUS
DKA & HHS
DR MOHAMMAD DAOUD CONSULTANT ENDOCRINOLOGIST KAMC -JEDDAH
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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?
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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 ?
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OBJECTIVES
Introduction
Pathogenesis
Clinical Picture
Management ; Your Role
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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
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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 !
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ACUTE DIABETIC COMPLICATIONS
1-Hyperglycemia : High
-Diabetic Ketoacidosis (DKA)..Type 1 DM
-Hyperosmolar Hyperglycemia Syndrome (HHS) ..Old Type 2 DM
2-Hypoglycemia : Low
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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?
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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?
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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)
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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
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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
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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
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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
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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 )
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HYPERGLYCEMIA
Due to variable reasons…
Insulin deficiency (Absolute / Relative) Insulin Resistance
Excess counter regulatory hormones (Glucagon, Cortisol…)
Defected secretion of GLP-1…
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Electrolyte LossesRenal Failure
Shock CV Collapse
INSULIN DEFICIENCY
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Hyperglycemia
Hyper-osmolality
Δ MS
CV Collapse
Glycosuria
Dehydration
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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
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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
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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)
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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
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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)
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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
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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
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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
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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
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HYPERGLYCEMIADKA
Inadequate insulin & excess glucagon,catecholamines…
Body cannot burn glucose properlyGlucose builds up in the bloodstream
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HYPERGLYCEMIADKA
Symptoms of DKA include:
Nausea, vomiting Abdomen/Stomach pain
Frequent urination Excessive thirst
Weakness, fatigue Speech problems
Confusion /Unconsciousness
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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
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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
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HYPERGLYCEMIAHHS
1- Severe hyperglycemia 2- S. Osmolality > 320 msom/kg
3- Severe dehydration 4- No ketonemia 5- No acidosis
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HHS
There is just enough insulin
to keep fat in fat cells and prevent ketone /acids formation
ketone levels are usually normal in HHS.
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Hyperglycemia
Hyperosmolarity
Ketoacidosis
HHSDK
A
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Take Home Messages
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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
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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
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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
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TO PREVENT = EDUCATION • ADHERENCE /COMPLIANCE TO RX : BASAL INSULIN / CORRECTIVE DOSES …ETC
• SICK DAYS RULES
• RECOGNIZE CLINICAL PICTURE / SMBG
• SEEK MEDICAL CARE WHEN NEEDED40