1. Endocrinology Continued
Joanna Smith

2. Diabetes Mellitus Type 1 Type 2 Absolute insulin deficiency
Autoimmune islet cell destruction
Relative insulin deficiency
Insulin resistance
Insufficient production

3. Diabetes Mellitus – Diagnosis
Symptomatic patient
HBA1c
Fasting glucose ≥ 7.0 mmol/l
Random glucose ≥ 11.1 mmol/l
Post 75g OGTT ≥ 11.1 mmol/l
Above criteria on 2 occasions
HbA1c ≥ 48mmol/mol (6.5%)
A normal HbA1c does not exclude DM
Asymptomatic patient

4. Diabetes Mellitus – Management
Principles
Normalise blood glucose levels
Monitor and treat complications
Modify risk factors e.g. CV disease

5. Diabetes Mellitus – Management
Type 1
Always require insulin
Different insulin choices depending on duration of action
Type 2
Majority controlled on oral medication
First line → metformin
Second line → sulfonylurea, gliptins, pioglitazone
Oral medication fails → insulin

6. T2DM – Lifestyle Modifications
Diet
Exercise
Smoking cessation
Lipids control
BP control
Antiplatelets

7. Any drug which may cause hypoglycaemia
T2DM – Management
Intervention
Target HbA1c
Lifestyle
48mmol/mol
Lifestyle + Metformin
Any drug which may cause hypoglycaemia
53mmol/mol
NICE encourage relaxing targets on a case by case basis, especially in the elderly or frail

8. Diabetic Emergencies

9. Diabetic Ketoacidosis
↓ Insulin
↑ stress hormones and ↑ glucagon
↑ gluconeogenesis
↑ serum and urine glucose
Osmotic diuresis
Dehydration
↓ glucose utilisation
Vomiting
↑ fat β-oxidation and ↑ fatty acids
↑ ATP and production of ketone bodies
Ketoacidosis

10. DKA – Clinical Features
Precipitants → stress, illness, stopping insulin, new T1DM
Abdominal pain
Vomiting
Drowsiness
Kussmaul Respiration
Dehydration
Ketotic breath

11. DKA – Diagnosis Need to show: Hyperglycaemia → BM/lab glucose
≥ 11.1 (or known diabetic)
Ketosis → urinary or blood ketones
≥ 3mM or ≥ 2+ on urinalysis
Metabolic acidosis → Blood Gas
pH < 7.3

12. DKA – Immediate Management
Oxygen
IV Access
Fluid replacement → 0.9% NaCl 1L over 1 hour
Insulin → 50units Actrapid in 50mls 0.9% Saline → 1unit/ml
Infusion at 6units/hour to start
Continue basal long-acting insulin along with infusion
Call for senior help
Other considerations → ECG, NG tube, catheter, identify cause (e.g. infection), VTE Prophylaxis

13. DKA – Ongoing Management
IV Fluids → rapid restoration of circulating volume, gradual correction of interstitial/intracellular deficits
1L 0.9% Saline over 2nd hour + Potassium if < 5
500ml 0.9% Saline over 3rd hour + Potassium if < 5
500ml 0.9% Saline over 4th hour + Potassium if < 5
Add in 10% dextrose when BM ≤ 14
A lot of blood tests!!
Hourly lab glucose
Titrate insulin infusion rate to BMs

14. Hypoglycaemia Blood Glucose < 4mmol/L
Mild Hypoglycaemia Sweating Tachycardia Hungry Anxious
Severe Hypoglycaemia (BM~ 2mmol/L) Confusion Dizziness Weakness Drowsy

15. Hypoglycaemia – Causes
Mostly patients on insulin or sulphonylureas
Lack of food
Unaccustomed exercise
Alcohol
Excess Insulin
Treat on basis of BM, but always confirm with lab glucose

16. Hypoglycaemia Conscious? No Yes ABCDE Stop IV Insulin
15-20g quick acting carbohydrate
Glucotabs
Fruit juice
Glucogel
ABCDE
Stop IV Insulin
20g long acting carbohydrate
Call for help
IV 10% dextrose or
1mg IM Glucagon
Yes No
Unsuccessful after up to 3 repeats
Successful

17. Hyperglycaemic Hyperosmolar Syndrome
Common in frail and elderly
30% mortality
Type 2 diabetes
Hyperglycaemia (often > 30mmol/l)
Not acidotic
No ketonuria
Relative insulin deficiency
↑ stress hormones and ↑ glucagon
↓ glucose utilisation
↑ gluconeogenesis
↑ glycogenolysis
↑ serum and urine glucose
Osmotic diuresis
Dehydration and hyperosmolarity

18. HHS – Clinical Features
Severe hyperglycaemia
Hyperosmolarity (>320mosmol/kg)
Profound dehydration
Prerenal uraemia
Very high sodium
Reduced GCS

19. HHS – Management
1. Fluids → 0.9% NaCl 1000ml 1st hour then 500mls each hour after (slower than DKA)
2. Insulin once rehydrated
3. Potassium replacement (aim ) after 1st bag of fluids
4. DVT Prophylaxis

20. Hyperkalaemia

21. Hyperkalaemia K+ > 5.0 Most important intracellular cation
mmol/L = Mild
> 6.0 mmol/L = Potentially serious
> 7.0 mmol/L = Medical Emergency → requires treatment
Most important intracellular cation
Renally excreted

22. Hyperkalaemia – Causes
Haemolysed sample
Iatrogenic
AKI/CKD
Potassium sparing diuretics
Addison’s disease
Excessive release from cells – burns, rhabdomyolysis, massive haemolysis

23. Hyperkalaemia – Clinical Features
Asymptomatic
ECG
Weakness
Small P Waves
Broad QRS
Palpitations
Tall, tented T waves
Dizziness
Sine Wave → VF → Asystole
Chest Pain

25. Hyperkalaemia – Treatment
***Get Help***
1. 10ml 10% Calcium Gluconate (If ≥ 7.0 mmol/l or ECG Changes)
Give with continuous ECG monitoring
Stabilises myocardium
2. 10units actrapid + 50ml 50% dextrose
3. 5mg Salbutamol nebs
4. Consider Calcium resonium or dialysis
5. Treat the cause

26. Interesting Case 47y/o male Clinic admission
Type 1 diabetic, vomiting past 2 weeks
Admitted to “sort pre-op”

27. Investigations & Management
No ketonuria
pH 7.32 on ABG
Clinically very dry
Cool to midarms
CRT 5s

28. Immediate Management
Hyperkalaemia
Fluids
Sliding scale

29. Hyperkalaemia – Treatment
***Get Help***
1. 10ml 10% Calcium Gluconate (If ≥ 7.0 mmol/l or ECG Changes)
Give with continuous ECG monitoring
Stabilises myocardium
2. 10units actrapid + 50ml 50% dextrose
3. 5mg Salbutamol nebs
4. Consider Calcium resonium or dialysis
5. Treat the cause