1. Diabetic Emergencies Aaqid Akram MBChB 2013 Clinical Education Fellow

2. Objectives Recognising and managing hypoglycaemia Recognising and managing Diabetic Ketoacidosis (DKA) Recognising and managing Hyperosmolar Hyperglycaemic State (HHS)

3. Hypoglycaemia - Causes Diet Alcohol Missed meals Exercise Medication Weight loss Stress Hot weather Injection site Pregnancy

6. Diabetic Ketoacidosis (DKA) Blood Glucose ↑ Ketones (blood/urine) ↑ pH ↓ If only 1 or 2 of the three – IT IS NOT DKA FBC/U+E/plasma glucose/VBG

7. Reassess response to Treatment Ketones falling >0.5mmol/L/HrHCO3 rising >3mmol/L/HrBlood Glucose falling > 3mmol/L/Hr Fluid Monitoring CBG<14mmol/L: 10% dextrose @ 125ml/Hr K < 5.5: KCl 40mmol @ max 10mol/Hr Oliguria <0.5ml/kg/Hr: catheterise vomiting / reduced consciousness: NG tube + airway protection SpO2<92%: ABG + O2 Fluid Replacement Prescribe 8 hours2 x 1L over 2 hours1 x 1L over 4 hoursPrescribe added KCl as required Think about precipitating factors ECGCXRUrine MC+SBlood cultures Bloods Capillary glucose/ketones every hourpH + K every 2 hoursHCO3 + U&E every 4 hours Continue long acting insulin Fixed Rate Insulin Infusion 50 units Actrapid + 50ml 0.9% NaCl0.1 units/kg/hr Fluid Resuscitation 500ml crystalloid 10-15 minsNo response: Senior Input

8. Hyperosmolar Hyperglycaemic state (HHS) Osmolality >320 mosmol/kg – Glucose + urea + (2 x Na) Hyperglycaemia – >30 mmol/L Hypovolaemia No significant ketones in urine/blood No significant acidosis There may be a mixed HHS and DKA picture – consult senior

9. Alert diabetes specialist team Urinary catheterisation Measure Urine Output (minimum 0.5 ml/kg/Hr)Calculate fluid balance Investigations Blood glucoseU+EMeasure osmolalityVBG Ketones (Urine/blood) ECG / CXR / Urine MC+S Clinical Assessment SepsisVascular eventChange in DHxDehydrationMental State Exam IV insulin infusion (Fixed rate) ONLY if ketones present0.05units/kg/hour IV Fluids 0.9% NaCl 1L over 1 hour (Potassium supplementation as required)

10. IV Fluids 12 hours: 3-6L 6 hours: 2-3L Aim positive balance

11. Osmolality Declining >8 mosmol/kg/Hr Reduce rate of IV fluid +/- Insulin (if commenced) Declining <3 mosmol/kg/Hr Check fluid balance (FB)Inadequate FB: increase rate Adequate FB: change to 0.45% NaCl at same rate Declining appropriately Continue on 0.9% NaCl Measure every 2 hours (1 st 12 hours) Glucose + Urea + 2NaReduce by 3-8 mosmol/kg/Hr

12. Glucose Aim blood glucose 10-15 mmol/L If BG <14 mmol/L: commence 5% dextrose 125ml/Hr + 0.9% NaCl Declining <5 mmol/L/Hr Check fluid balance (FB) Inadequate: increase rate of 0.9% NaCl Adequate: commence insulin infusion Measure at least every 2 hours (1 st 12 hours) Aim for minimum 5 mmol/L/Hr decrease