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Emergencies in Diabetes: R Bowo Pramono Perkeni Cabang Yogyakarta
Emergencies in Diabetes: R Bowo Pramono Perkeni Cabang Yogyakarta
TEGAL 27-jan 1959 Istri: dr. Astuti, SpS, 2 putri Dokter Umum: FK UGM 17-01-1985 SpPD : FK UGM 24-11-1997 K-EMD : 14-05-2008 Pekerjaan: 1987-2002 PKM Kedung Waringin Bekasi 1999-2004 RSU Selong Lombok Timur 2004-2011 RS DR Sardjito/FK UGM
2
DISCUSSION
HYPOGLYCEMIA
Hypoglycemia is a blood glucose value of less than 50 mg/dl Clinically, it is defined by Whipple triad: low plasma glucose level, symptoms consistent with hypoglycemia, and resolution of symptoms with correction of plasma glucose
Epidemiology
30% of type 1 or type 2 diabetic patients on insulin therapy 10% of type 2 diabetic patients Mortality rate 3-4% especially elderly taking long acting oral hypoglycemic agents
Symptoms
Adrenergic symptoms (catecholamine mediated): diaphoresis, palpitations, pallor, tachycardia apprehension, anxiety, sensation of hunger headache, weakness, restlessness
Neuroglycopenic symptoms: reduced intellectual capacity, irritability, confusion, abnormal behavior, convulsion, coma
Glucoregulatory factors
Blood-glucose-lowering factor
Insulin
in minutes In hours
Blood glucose 56-48 mg/dl * adrenalin secretion * diaphoresis, tremor * reduced function of central nervous system Blood glucose <48-36 mg/dl * reduced consciousness Blood glucose <36-18 mg/dl * coma, convulsion Blood glucose <18 mg/dl * permanent brain damage
Defective glucose counterregulation Impaired awareness of hypoglycemia Elevated glycemic threshold during intensive therapy Elevated glycemic threshold following recent hypoglycemia Elevated glycemic threshold during -adrenergic blockade
Autonomic failure
The syndromes may occur in advanced type 2 diabetes mellitus (insulin-deficient)
Risk factors
Tight glycemic control Age Duration of diabetes History of hypoglycemia Sleeping Alcoholism Fasting Increased insulin sensitivity: fitness, body weight Clearance/metabolism of drugs: renal or hepatic insufficiency
Increase in half-life due to inhibition of metabolism or excretion rate: ethanol, phenylbutazone, coumarin anticoagulants, chloramphenicol, doxycycline, sulfonamides, allopurinol
Management of hypoglycemia
Mild hypoglycemia when self treatment with oral carbohydrate suffices Sever hypoglycemia when external help is required to effect recovery
5.
Early familiarization with the symptoms of hypoglycemia Do reviewing at intervals Explain the relationship between insulin administration, timing of meals, and exercise Explain methods of self-treating hypoglycemia Choose appropriate insulin regimens, dose schedules with appropriate therapeutic goals
Mild hypoglycemia: oral glucose 15-20 g, wait 10-15 min then check blood glucose. If glucose level does not increase 18 mg/dl, give oral glucose again Severe hypoglycemia: solution 50 ml of dextrose 50% given intravenously, check blood glucose in 20 min. If it is still hypoglycemia administrate once again Glucagon 1.0 mg s.c/i.m/i.v. adverse effects include nausea, vomiting, and headache. Contraindicated to sulfonylureas-induced hypoglycemia. Ineffective in patient who is anorectic, or with protracted hypoglycemia
DIABETIC KETOACIDOSIS
AND
HYPERGLYCEMIC HYPEROSMOLAR STATE
laktic acid
Occurs when muscle cells become so starved for energy that body takes emergency measures & breaks down fat toxic acids as ketones Most common type 1 DM insufficient insulin to adjust raise of blood sugar Cause by extreme stress or illness Infection body produce adrenalin works against insulin Forget to take insulin
Deep, rapid breathing Sweet, fruity smell on breath Loss of appetite Nausea Fatigue Vomiting Weakness Fever Confusion Stomach pain Drowsiness Weight loss
Clinical presentation
Lost more than 5% body weight More than 35 breaths a minute Cant control blood sugar Become confused Nausea and vomiting
Check ketones if feeling especially stressed or blood sugar persistently above 240mg/dL High ketones in blood ketones excreted in urine. High ketones in urine should be treated & n hospitalized DKA can lead into coma and possibly death.
Treatment
Correcting lost fluids through i.v. line Glucose infusion with insulin may stop ketones production Decrease blood sugar level gradually, decreasing glucose rapidly may produce brain swelling
< 60 = Hypoglycemia (need dextrose Tx) 60-70 0 0 0 0 70-109 0,2 0,5 1 1,5 110-119 0,5 1 2 3 120-149 1 1,5 3 5 150-179 1,5 2 4 7 180-209 2 3 5 9 210-239 2 4 6 12 240-269 3 5 8 16 270-299 3 6 10 20 300-329 4 7 12 24 330-359 4 8 14 28 >360 6 12 16 28
A high level of blood glucose may interfere blood circulation (level >600 mg/dl) Glucose uptake by the cells decreases, the glucose passed from blood to urine draws tremendous amounts of fluid from body and produces dehydration Common in type 2 DM, especially who does not monitor blood sugar, and who does not know have DM Trigger factors: high-dose steroid, diuretics, infection, illness, stress or drinking excessive alcohol
Excessive thirst Increased urination Weakness Leg cramps Confusion Rapid pulse Convulsions Coma
Check blood glucose level (> 600mg/dL) Emergency treatment can correct the problem within hours Give intravenous fluids to restore water to the tissue Short acting insulin to help cells can uptake glucose Without prompt treatment can be fatal