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HYPOGLYCEMIA,HYPEROSMOLAR HYPERGLYCAEMIC
STATE (HHS)
AND DIABETIC KETOACIDOSIS (DKA)
Adrian Yusdianto
Vika Cahyani Yoningsih
Najmulhadi B Mohd SahriNurul Hakimmah Bt Abd Manan
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Hypoglycaemia may be defined as a low bloodglucose level, usually ofless than 3.0 mmol/l
(
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Always check a stat capillary blood sugar on
ANY patient presenting with altered mental
state/seizures
Capillary blood sugar readings read lower than
venous readings
artificially lower readings inhypotension, hypothermia and oedema. Hence,
always confirm hypoglycaemia with a VENOUS
sample to the lab
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CAUSES
HEALTHY-APPEARING PX
Medications/
drugs
Intenseexercises
Insulinoma
ILL-APPEARING PX
Sepsis/shock Infection
Starvation,anorexia nervosa
Liver/cardiac/renalfailure
EndocrineNon-islet cell
tumour
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50%
Insulin/oralhypoglycaemic
agent (OHA)
Intentional/
accidental overdose
Excess dose, illtiming, wrong type
of insulin
Decreased ofclearance due to
renal failure
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Clinical Features
AUTONOMIC (BSL 2.8-3.0 mmol/l) Shaking
Trembling
Diaphoresis
Tachycardia Pallor
NEUROGLYCOPENIA (BSL
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Management
Low flowoxygen
Monitor : ECG,pulse oxymetry,
vital signs
Check capillaryblood glucose
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History
Check for diabetes mellitus, medication
history, recent change in drug doses, recent
and chronic illness.
If patient is unconscious, obtain history from
caregivers/family.
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INVESTIGATION
Venous blood glucose,
urea, electrolytes,
creatinine, liver function
tests, FBC
Non-diabetic draw 5-
10 ml blood sample for
serum insulin, C peptides
and cortisol prior to giving
treatment to help the in-patient team in the
subsequent endocrine
evaluation for patient.
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Treatment
Fully conscious patient
Oral therapy give a
carbohydrate rich drink (Eg
Milo, Horlicks, Ensure,orange juice) and feed the
patient.
Unconscious patient
IV Dextrose 50% 40-50ml
If IV access in unavailable/very
uncooperative patients, IM/SCglucagon 1mg may be given.
Chronic alcoholism IV
thiamine 100 mg
Adrenal insufficiency IV
hydrocortisone 100-200 mg
Injury tetanus prophylaxis
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Adult hypoglycemia treatment
by American Diabetic
Association
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The majority of patients
should recover in 20-30
minutes.
If there is a persistent
altered mental state
despite the resolution of
hypoglycaemia, other
pathology must be
considered, and a CT scanof the brain may be
indicated!
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HYPERGLYCAEMICEMERGENCIES
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Diagnostic Criteria
Diabetic Ketoacidosis (DKA)
Blood glucose >or equal to
14 mmol/l
Acidaemia with arterial pH7.3,
bicarbonate >15 mmol/l Absence of severe
ketonaemia/ketonuria
Serum total osmolality >330
mOsm/kg H2O OR serumeffective osmolality >320
mOsm/kg H2O
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Clinical Features
Polyuria,polydipsia,
nocturiaWeight loss Hyperventilation
Acetone breath Vomiting Abdominal pain
Hypotension Drowsiness Coma
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Causes
Infection
Infarction
Insufficientinsulin
Intercurrentillness
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Laboratory
FBC
Uea/electrolytes/creatinine/calcium/magnesiu
m/phosphate/serum
osmolality/ABGs/urinalysis
Monitoring ECG, pulse oxymetry, vital
signs, blood glucose and potassium every 1-2
hours
Urinary cathater to monitor urine output
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Management
I. Fluid Replacement (First hour)
Administer normal saline at 15-20 ml/kg/h in
the first hour, with recourse to colloids if
patients is still hypotensive.
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Management
Fluid Replacement (next 2-4 hours)
SerumNa
HIGH
0.45%
NaCl 10-20ml/kg/h
S
erumNaNO
RMAL
0.45%
NaCl 10-20ml/kg/hr
SerumNaLOW
0.9%
NaCl 10-20ml/kg/hr
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Management
II. Restoration of Electrolyte Balance
20-40 mEq KCl per hourSerum K
5 mmol/l
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Management
III. Restoration of Acid-Base Balance
pH 6.9-7.9
50 ml 8.4%NaHCO3,dilute in 200
ml NS and runover 1 hour
pH
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Management
IV. Insulin Administration
Bolus dose of0.15 units/kg BW
SI
Low dosecontinuous
infusion of 0.1units/kgBW/hour
Blood glucose
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