An approach to patient with hypoglycaemia

Whipples triad SSx consistent with hypoglycaemia Documented glucose level low Treatment given causes SSx resolves

Definition of hypoglycaemia: For healthy individual DXT < 3.0 mmol/L For DM patient DXT < 3.8 mmol/L

SSx Autonomic (peripheral NS) Shaking, trembling, sweating, palpitation, hunger, pins and needles in lips and tongue etc. Neuroglycopenic (CNS) Confuse, anxiety, couldnt concentrate, abnormal mental state, irritable, focal neurological signs, impaired vision etc.

Precipitating causes Underlying liver or renal diseases (source of gluconeogenesis)

 OHA Glibenclamide used more in KK, higher risk of hypoglycaemia than others because it has more prolonged action Gliclazide Metformin Cortisol deficiency Insulinoma etc

Management 1.Withhold all OHA or insulin. 2.If mental functions intact and tolerating orally, give 15g carbohydrates 1-2 tablets of glucose/sweet 3 teaspoon of sugar 1-2 cups of milk, orange juice Pieces of fruits 3 pcs of crackers 1-2 pcs of bread/sandwich Repeat DXT after 15 min. If still <3.9, give another 15g carb. 1. If minimal hypo, could not tolerate orally give 30-50cc D50% then repeat DXT monitoring 2. If persistently hypo (usually due to OHA) give 50cc D50% + 25g Carb + IV 1 pint D10% /24hrs 3. To consider IM glucagon if difficult IV access, once regain consciousness, to encourage orally 4. For pt who remain unconscious due to prolonged hypoglycaemia, start IV Dexa 4mg QID or IV Mannitol to treat cerebral oedema, and find out other causes of coma (drug overdose or stroke)

An approach to patient with hyperglycaemia

Posted: May 22, 2012 by kiamseong in Medicine

Mortality caused by DKA and HHS = 30% Precipitating factors

 Noncompliance to medication Infection Pancreatitis Myocardial infarction Steroid Thiazide Stroke etc.

Difference between DKA and HHS In DKA ~ absolute insulin deficiency > induce lipolysis > ketone formation In HHS ~ relative insulin deficiency

Differential diagnosis If presence of ketone can be also due to: Starvation Alcohol

DKA To diagnose must fulfil these 3 criteria: pH < 7.3 glucose > 14 blood ketone > 2

Severity:

Mild Moderate Severe

pH 7.25-7.30 HCO3 15-18 Alert pH 7.00-7.24 HCO3 10-14 Drowsy pH <7.00 HCO3 <10 Stupor/Coma

HHS To diagnose must fulfil these 2 criteria: glucose > 33 serum osmolarity > 320 mOsm/L HCO3 > 18

Mental status drops if osmolarity -increased

Ix DXT Ketone stick ABG/VBG RBS (esp DXT HI) BUSE, Creatinine Serum ketone Serum osmolarity UFEME FBC ECG CXR Blood C+S

 HbA1c

Mx of Hyperglycaemia 1. Fluid replacement 2. Insulin 3. Electrolyte correction 4. Treat precipitating cause

Fluid replacement Set 1 line in each arm One for running bolus One for maintenance

For deficit DKA 6 litres, HHS 9 litres Run in bolus 1 litre in 1 H 1 litre in 2 H 1 litre in 4 H 1 litre in 6 H 1 litre in 8 H

Maintenance calculated by Holliday Segar formula

Choice of fluid If hyperNa or EuNa use HS If hypoNa use NS

Always start from fluid replacement because: To prevent hypotension To obtain K+ result before insulin therapy Insulin effectiveness decrease if hyperosmolar not corrected Sufficient fluid therapy decrease counteracting hormones

Insulin therapy Not to start if K < 3.3 IV regular insulin 0.1U/kg bolus then 0.1U/kg/H per sliding scale Target to reduce glucose level 2.7-3.8 mmol/L/H Not too fast can cause cerebral oedema If cannot reach target double the dose

Target glucose level: (keep till DKA/HHS resolves) DKA 8-11mmol/L HHS 14-16 mmol/L

In DKA if patient in hypoglycaemia cannot stop insulin therapy because it can cause ketoacidosis due to lipolysis To give insulin but give patient on D10%

Electrolyte correction Check BUSE and VBG QID

Criteria to start K replacement: No ECG evidence of hyperkalemia K < 5mmol/L Good urine output 0.5cc/kg/H

To correct hypokalemia (as a result of insulin therapy), include in each/alternate pint fluid in maintenance drip 0.5-1g KCl

Hyperglycaemia resolution (at least 3 criteria) DKA Glucose < 11 HCO3 > 18 pH > 7.3 Anion gap < 12 HHS Serum osmolarity < 320 Gradual recovering mental alertness

Formula: AG = Na + K Cl HCO3

After resolve, if patient tolerating orally Change to basal bolus regime (0.5-0.8 U/kg/day) and titrate with overlapping 1-2hrs with sliding scale

Indication of bicarbonates If pH 6.9-7, gives 50cc HCO3 in 200cc HS with 10ml KCl over 2hrs If pH < 6.9 gives double dose

Be aware of fluid overload in elderly or when massive replacement is required. Consider CVP monitoring.