MANAGEMENT_OF_DM_EMERGENCIES and treatment

A detailed slide on the management of DM emergencies

1. MANAGEMENT OF DM EMERGENCIES DR UNYIME JACKSON AFROMEDIC MENTORS

2. CONTENTS Introduction/Definition DM emergencies Management Further management/prevention Complications Challenges with management Conclusion

3. ABBREVIATIONS ABG – Arterial Blood Gases AKI – Acute Kidney Injury BP – Blood Pressure CCB – Calcium Channel Blocker CRT – Capillary Refill Time CVD – Cerebrovascular Disease CXR – Chest Xray DKA – Diabetic Ketoacidosis DM – Diabetes mellitus DPP –Dipeptidyl Peptidase DVT – Deep Vein Thrombosis ECG - Electrocardiogram E/U/Cr – Electrolyte/Urea/Creatinine

4. ABBREVIATIONS FBG – Fasting Blodd Glucose FLP – Fasting Lipid Profile GCS – Glasgow Coma Scale GDM –Gestational Diabetes Mellitus GLP –Glucose-like Peptide HHS – Hyperglycaemic hyperomolar state IM – Intramuscular IV - Intravenous IVF – Intravenous Fluid LADA – Latent Autoimmune Diabetes in Adults M/C/S –Microscopy/Culture/Sensitivity MI – Myocardial Infarction

5. ABBREVIATIONS MODY – Maturity onset Diabetes of the young N/S – Normal Saline NPH – Neutral Protamine Hegedon PR – Pulse Rate RR – Respiratory Rate R/L – Ringers Lactate RBG – Random Blood Glucose UTI – Urinary Tract Infections S/C - Subcutaneous SGLT – Sodium Glucose Co-Transporter USS – Ultrasound Scan

6. CASE PRESENTATION A 14-year old girl with type 1 DM is rushed into the children emergency ward by her parents. They say that she has been vomiting for the past 18 hours and she suddenly stopped responding to them about 30 minutes ago. They also mention that she had a high-grade fever, chest pain and cough which was productive of rusty-coloured sputum a few days earlier. On examination, she is lethargic, febile, and pale. CRT is 5 sec. Her breathing is very fast and deep. Her BP is 80/50mmHg, PR is 140b/min and very weak, RR is 36 cycles/minute. A fruity odour is noticed in her breath.

7. CASE PRESENTATION CONT’D What is the next best step to take in the managemnet of this patient: A – Give IV insulin 10 I.U loading dose then maintain with 6 I.U hourly B – Give S/C insulin 10 I.U loading dose then maintain with 6 I.U hourly C – Carry out a sputum m/c/s and start intravenous antibiotics to treat the infection D – Catheterize the patient and pass a nasogastric tube

8. INTRODUCTION DM is a chronic disorder of carbohydrate, protein and fat metabolism characterized by persistent hyperglycaemia > 7mmol/l (FBG) or > 11.1mmol/l (RBG) due to relative or absolute deficiency of insulin Major types are type 1 and type 2 DM. Others include GDM, MODY, LADA, drugs, endocrinopathies, genetic disorders Patients usually present with a history of polyuria, polydipsia, polyphagia (type 1 DM) or they may present for the first time as an emergency due to an acute complication (type 2 DM).

9. COMPLICATIONS OF DM 1) Acute - Diabetic ketoacidosis - Hyperglycaemic hyperosmolar state - Hypoglycaemia - Lactic acidosis

10. COMPLICATIONS OF DM 2) Chronic Microvascular - DM nephropathy - DM neuropathy (somatic, autonomic) - DM retinopathy Macrovascular - MI - Cerebrovascular dx - Peripheral vascular dx

11. DM EMERGENCIES These are potentially life-threatening conditions in individuals with DM occurring either due to very high or dangerously low blood glucose levels They include: 1) Diabetic ketoacidosis 2) Hyperglycaemic hyperosmolar state 3) Hypoglycaemia 4) Lactic acidosis

12. DIABETIC KETOACIDOSIS Definition: A state of uncontrolled catabolism associated with insulin deficiency. Most common endocrine emergency. Commonly seen in type 1 DM, but may occur in type 2 DM. Mortality 2-5% in developed world, but higher 20-30% in developing countries.

13. PRECIPITATING FACTORS Newly diagnosed diabetic (20-30%) especially type 1. Failure to take insulin, faulty insulin delivery system Infections, UTI/respiratory (RTI) (30-40% cases), gastroenteritis, sepsis Unknown (20-25% cases) Miscellaneous- pregnancy, alcohol, cocaine, infarction(CVD/myocardial, mesenteric, peripheral), drugs (glucocorticoids, thiazides), trauma, psychological stress, mental health disorders.

14. PATHOPHYSIOLOGY

15. CLINICAL FEATURES Usually acute, within hours to a few days. Hyperglycaemia- polyuria, polydipsia, weakness, abdominal pain. Dehydration Acidosis- nausea, vomiting, hypotension. Coma, lethargy Kussmaul respiration (deep and rapid, noisy, regular), tachypnoea, respiratory distress

16. Febrile/afebrile (even in the presence of infection) Acetone breath with fruity odour Symptoms of the precipitating illness e.g UTI, pneumonia, MI. Signs of cerebral oedema Hypotension, tachycardia AKI

17. DIAGNOSIS 1) Random blood glucose - Hyperglycaemia;>250mg% (14mmol/L)-600mg%(35mmol/L 2) Arterial blood gases - Metabolic Acidosis pH <7.35 (HCO3<15mmol/L 3) Urinalysis - Ketonuria 2+ (or more) and/or blood ketone> 6mmo/l 4) Anion gap >15 mmol/L. Anion gap = (Na+ + K+) – (HCO3- + Cl-) Normal anion gap = 10–14 mmol/L

18. DIAGNOSIS 5 ) Serum E/U/Cr - r aised urea, r aised creatinine , hypernatraemia, n ormal osmolality 6 ) Full blood count - Leucocytosis > 20-25,000/cm3 (if > 25,000 it is suggestive of infection) 7 ) O ₂ Saturation

19. MANAGEMENT Management principles: 1) Restore perfusion/rehydration 2) Stop ketogenesis by insulin replacement 3) Correct electrolytes imbalance 4) Avoid c omplications 5) Treat the underlying cause/precipitants

20. MGT CONT'D a) RESUSCITATE – A-B-C b) Draw blood for investigations 1 . E/U, Cr-URGENT 2 . Plasma glucose hrly & electrolytes 8hrly in 1st 24 h rs . Then daily E/ U,Cr until stable- MUST 3 . Do bedside urinalysis for sugar, ketones and proteins- URGENT 4 . ABGs- Urgent if possible. 5 . Urine M/C/S 6 . Full blood count

21. MGT CONT'D 7 . ECG (to r/o MI or dyselectrolytemia) 8 . Arrange for chest X-ray c) Catheterise if unconscious or when there is no spontaneous urine in 3 hours. d) Give 60-100% oxygen 4-5L/min if the PaO2 is <11KPA ( 80mmHg) e ) NG Tube if unconscious or semi unconscious (GCS<6/15) f) Central venous line if elderly (>65yrs) or in cardiac patients.

22. MGT CONT'D FLUID REPLACEMENT : Estimated fluid loss is approx. 6-8L. Replace 4L in the 1st 8hrs. Give 1L normal saline over 30minutes, then 1L over 1 hour, then 1 L over the next 2hrs, then 1 L over the next 4hrs, then

23. MGT CONT'D Continue rehydration at the rate of 1 L over 4-6hrs depending on hydration status. Change normal saline to 5% dextrose when the blood sugar falls to <14mmol/L U se dextrose saline when the patient’s BP remains <100mmHg.

24. MGT CONT'D INSULIN MANAGEMENT S tat 10 IU IV and 10 IU IM as loading dose. Then 6u hrly until plasma glucose falls below 14mmol/L. If RBS fall is <3mmol/L/ Hr , double the dose of insulin Then continue as 6u 2hourly

25. MGT CONT'D Change to TDS soluble insulin S/C if hydration is adequate Titrate dose of insulin until the plasma glucose normalise , then convert the p atient to intermediate/soluble Mixtard O r the patient be placed on his previous doses of oral agents, if stress factors like infection have been satisfactorily controlled

26. MGT CONT'D POTASSIUM CORRECTION Correct only; i. After the first litre of normal saline and the patient is making urine ii. When serum potassium is < 5.5 mmol/L iii. When there is ECG evidence of hypokalaemia

27. MGT CONT'D POTASSIUM(mmo/l ) AMOUNT in IL IVF >5.5 Observe. No KCL 4.5 – 5.4 13 3.5 – 4.4 26 <3.5 39

28. MGT CONT'D BICARBONATE (HCO3) No demonstrable clinical benefit from HCO3 administration when the PH > 7.0

29. MGT CONT'D TREATMENT OF PRECIPITATING CAUSES Start broad spectrum antibiotics for suspected infection (UTI/Chest) after samples for microbiology have been taken. Treat infarction, trauma Discontinue precipitating drugs

30. HYPERGLYCAEMIC HYPEROSMOLAR STATE Hypovolaemia ( loss of 8-12 l) Marked hyperglycaemia (>30 mmol/L) without significant hyperketonaemia (<3.0 mmol/L) or acidosis (pH>7.3, bicarbonate>15 mmol/L) Osmolality >320 mosmol/kg (normal 270-290mosm/L)

31. PRECIPITATING FACTORS Serious concurrent illnesses eg MI, stroke, sepsis, pneumonia, UTI, cellulitis, dental infection, other infections, renal failure, pancreatitis, severe burns, thyrotoxicosis, hypo/hyperthermia, Cushing syndrome, pulmonary embolism . Social situations that compromise water intake may contribute to development of HHS eg dementia, immobility . Medications eg glucocorticoids, diuretics (loop & thiazide), CCBs, propranolol, cimetidine, some antipsychotics .

32. PATHOPHYSIOLOGY

33. CLINICAL FEATURES Usually elderly patients with type 2 DM History of polyuria, weight loss, decreased oral intake Mental confusion, lethargy, coma Profound dehydration, hypotension, tachycardia Features of AKI (acute kidney injury) Note absence of abdominal pain, N/V, kussmaul respiration as seen in DKA

34. DIAGNOSIS Marked hyperglycaemia >55.5mmol/l Hyperosmolality >350mosmoles/l Pre - renal azotaemia +/- acidosis and ketonaemia Slight increase in anion gap. Ketonaemia / ketonuria usually due to starvation

35. MANAGEMENT Management essentially same as DKA but ; Fluid replacement is with ½ normal saline Loading dose of insulin same The initial doses of insulin should be halved , but can then be increased if there is no appreciable response.

36. LACTIC ACIDOSIS May occur in DM p atients on biguanides Severe metabolic acidosis Almost normal glucose Large anion gap Low PH No ketones

37. Treatment Rehydration (N/S not R/L) Bicarbonate infusion

38. HYPOGLYCAEMIA Hypoglycemia, also called low blood glucose or low blood sugar, <3mmol/l O ccurs when blood glucose drops below normal levels. Primarily due to medications: diabetes, others, Systemic disease: end stage organ disease, sepsis, endocrine deficiencies and tumors

39. DIAGNOSIS WHIPPLE'S TRIAD Symptoms of Hypoglycaemia Low Serum b lood g lucose (BG) Relief of Symptoms with n ormalization of BG

40. SYMPTOMS NEUROGLYCOPENIC Altered mental status/coma Confusion Fatigue Seizure Loss of consciousness Death

41. SYMPTOMS CONT'D NEUROGENIC/AUTONOMIC Adrenergic Palpitations Tremor Anxiety CHOLINERGIC Diaphoresis Hunger Paresthesias

42. Symptoms of hypoglycaemia

43. MANAGEMENT Give 50% glucose 50-100ml bolus IV in double dilution using a large peripheral vein. Maintain on 10% dextrose water 1 Liter 6hourly until patient can take orally. This to avoid rebound hypoglycaemia. Monitor hourly blood sugar until stable Withhold all anti-diabetic medications including insulin until patient is stable. Alternatively, 1mg IM or S/C Glucagon can be given

44. MGT CONT'D However if patient is conscious and can tolerate oral ly , let them take half a bottle of soft drink, or 2-3 cubes of sugar, or one scoop of granulated sugar. To avoid rebound hypoglycaemia , patient should eat immediately. Monitor hourly blood sugar until stable Withhold all anti-diabetic medications including insulin until patient is stable

45. FURTHER MANAGEMENT After acute management and resuscitation of patient, it is important to: Take history Perform physical examination Carry out investigations Treat DM and/or other complications

46. HISTORY Biodata - NASOMART Complaint(s) - complaint - course - cause - care - complications

47. HISTORY Past medical and surgical history OnG history Drug/allergy history Family/social history Systemic review

48. EXAMINATION GPE (General physical examination) Systemic - Abdominal - Respiratory - Cardiovascular - Neurological - Musculoskeletal

49. INVESTIGATIONS Fasting blood glucose HbA1c Full blood count Urinalysis Serum E/U/Cr ECG, CXR, ECHO

50. INVESTIGATIONS CONT'D Doppler ultrasound Wound swab m/c/s, sputum culture, blood culture ABG FLP Abdominal USS Imaging of extremities

51. TREATMENT Goals of therapy are to: 1) Eliminate symptoms related to hyperglycaemia. 2 ) Reduce or eliminate the long-term microvascular and macrovascular complications of DM. 3) Allow the patient to achieve as normal a lifestyle as possible. Management is multidisciplinary involving the primary care provider, endocrinologist, nutritionist, psychologist, social worker as well as other doctors if complications arise (ophthalmologists, neurologists, nephrologists, podiatrists, cardiologists, cardiovascular surgeons)

52. ONGOING CARE Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes Individualized glycemic goal and therapeutic plan Self-monitoring of blood glucose (individualized frequency) HbA1c testing (2–4 times/year) Lifestyle management in the care of diabetes, including: - Diabetes-self-management education and support - Nutrition therapy - Physical activity - Psychosocial care, including evaluation for depression, anxiety

53. ONGOING CARE Detection, prevention, or management of diabetes-related complications i ncluding: - Diabetes-related eye examination (annual or biannual) - Diabetes-related foot examination (1–2 times/year by provider; daily by patient) - Diabetes-related neuropathy examination (annual) - D iabetes-related kidney disease testing (annual)

54. ONGOING CARE Manage or treat diabetes-relevant conditions, including: - Blood pressure (assess quarterly) - Lipids (annual) - Consider antiplatelet therapy - Influenza/pneumococcal/hepatitis B immunizations

55. DRUG MANAGEMENT OF DM 1) Insulin preparations - Rapid acting: lispro, aspart, glulisine - Short acting: regular - Intermediate acting: NPH - Long acting: determir, glargine 2) Insulin sensitizers - Biguanides: metformin - Glitazones/thiazolidinediones: pioglitazone, rosiglitazone

56. DRUG MANAGEMENT OF DM 3) Insulin secretagogues - Sulfonylureas: chlorpropamide, tolbutamide, glipizide, glyburide - Meglitinides: Nateglinide, repaglinide 4) Increase glucose-induced insulin secretion - GLP-1 analogs: Exenatide, liraglutide (subcut.) - DPP-4 inhibitors: Linagliptin, sitagliptin, saxagliptin

57. DRUG MANAGEMENT OF DM 5) Decrease glucose absorption - SGLT-2 inhibitors: Canagliflozin, Dapagliflozin, Empagliflozin - Alpha-glucosidase inhibitors: arcabose, miglitol 6) Others - Amylinomimetics: Pramlintide (subcut.)

58. COMPLICATIONS 1) Hypophosphataemia 2) Arrhythmias (hyperkalaemia) 3) Cerebral oedema 4) Mucormycosis 5) Severe dehydration 6) AKI 7) DVT 8) Cerebrovascular accident 9) Erosive gastritis

59. CHALLENGES WITH MANAGEMENT Management of DM emergencies is fraught with many challenges especially in low resource settings like Nigeria Some of these challenges include: Inadequate emergency response services Lack of finance (high cost of drugs etc) 3) Poor health funding by the government 4) 'Feeling of tiredness' by patients 5) Poor knowledge/education about DM and complications 6) Lack of adequate support systems for patients

60. CONCLUSION DM emergencies are a major cause of morbidity and mortality in patients with DM . They are one of the commonest presentations at the emergency departments in hospitals . Prevention as well as prompt diagnosis and treatment are important to prevent further complications . It is also important to assess for other complications in patients who present with these emergencies .

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