An approach to patient with hypoglycaemiaWhipple’s 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, couldn’t concentrate, abnormal mental state, irritable, focal neurological signs, impaired vision etc.

 

Precipitating causes

• Underlying liver or renal diseases (source of gluconeogenesis)• OHA§ Glibenclamide à used more in KK, higher risk of

hypoglycaemia than others because it has more prolonged action§ Gliclazide§ Metformin

• Cortisol deficiency• Insulinoma etc 

Management1.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/sandwichRepeat DXT after 15 min. If still <3.9, give another 15g carb.

1. If minimal hypo, could not tolerate orally à give 30-50cc D50% then repeat DXT monitoring

2. If persistently hypo (usually due to OHA) à 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 hyperglycaemiaPosted: May 22, 2012 by kiamseong in Medicine

0Mortality 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                        pH 7.25-7.30  HCO3 15-18 Alert

Moderate              pH 7.00-7.24  HCO3 10-14 Drowsy

Severe                    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 replacement2. Insulin3. Electrolyte correction4. 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 à use HS

If hypoNa à 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 à can cause cerebral oedema• If cannot reach target à 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

è  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                                       HHS

Glucose < 11                         Serum osmolarity < 320

HCO3 > 18                            Gradual recovering mental alertness

pH > 7.3                                               

Anion gap < 12  

 

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.