Emergency conditions in diabetes
Dr Wrishi Raphael
Emergency conditions in diabetes can be life threatening if not treated promptly. Over control of ones blood glucose level is dangerous and leads to life threatening hypoglycemia (low blood glucose) as glucose is the primary source of energy for the brain. A person whose diabetes is poorly controlled is in a precarious position as well, as emergency conditions like diabetic ketoacidosis and hyperosmolar hyperglycaemia are equally perilous and require prompt intervention, efficient laboratory support and frequent follow up.
Hypoglycemia:
Low blood glucose of 4mmol or less is hypoglycemia, which may cause patients to sweat profusely, shake uncontrollably and feel a sharp upsurge in their appetite. If hypoglycemia occurs during sleep, sleep will be disturbed along with excess sweating and a feeling of tiredness and confusion upon waking. Correction of this life threatening problem is the simplest of all as rapid correction can be easily obtained with sugary drinks, chocolates or sweets. But unconscious patients will need intravenous infusions of dextrose and quick hospitalization must be arranged.
Diabetic Ketoacidosis:
If the patient
presents in comatose state a multi sectoral approach is essential to help the patient. If underlying
infections like cellulitis and
pneumonia has been identified, treatment with antibiotics is vital. Certain drugs used in heart failure and hypertension like calcium channel blockers and diuretics may also precipitate hyperosmolar state and therefore must be reviewed by cardiologists and endocrinologists.
Ketone bodies are toxic metabolites which accumulate in the body due to the breakdown of amino acids. Due to a lack of insulin, the body cannot metabolize glucose to meet its energy requirements and starts to burn fats and amino acids instead; resulting in the accumulation of toxic ketone bodies as a by-product. The buildup of ketone bodies in the blood is dangerous as they indicate severe insulin deficiency and dehydration and the need for prompt hospitalization. These signs and symptoms may be the first indication of having diabetes and ketoacidosis. The patient may notice excessive thirst, frequent urination, nausea, vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, (more common during ketoacidosis) and confusion. Fruity scented breath is more common in ketoacidosis then properly controlled diabetes because the ketone bodies which have accumulated in the body are being excreted through the patients breath. Hospital based management requires vigilant follow up of blood glucose, osmolarity, ketone bodies, electrolyte levels and kidney function tests. Our blood flows through a closed system of vessels where pH levels are maintained within a strict range by various regulatory mechanisms inside the body.
These regulatory mechanisms are thrown off balance in diabetic ketoacidosis and thats why its very important to check blood acidity level during this perilous phase. Rehydration with intravenous saline, replacement of electrolytes and correction of hyperglycemia with insulin is the mainstay of treatment. Co morbidities like urinary tract, respiratory and cardiac problems should be checked with urine analysis, chest X-Ray and ECG.
Hyperosmolar Hyperglycemia:
This disease state may often be confused with ketoacidosis but there are considerable differences in the laboratory findings and management protocol of the two. The patient may present with seizures, or confusion or coma. Unlike ketoacidosis, hyperosmolar hyperglycemia may present in Type I (where there is insulin deficiency from birth) and Type II Diabetes. There is very little or no production of ketone bodies in this condition. But the hyperglycemia is severe and the resultant dehydration causes the osmolality of blood to rise significantly. Osmolality may be defined as the measure of osmotically active particles in blood; in simpler terms a summation of all electrolytes and molecules which are capable of osmosis. Because the water has drained away from the fluid portion of blood or plasma due to the uncontrolled hyperglycemia, blood becomes very concentrated with its constituent salts. This causes serious derangements like pH alterations, decreased level of consciousness and coma. The biochemical abnormalities which may help us to diagnose and differentiate hyperosmolar hyperglycemia from ketoacidosis may be summarized below.
Plasma glucose level of 600 mg/dL or greater. Although hyperglycemia will be present in ketoacidosis but it will never be so high.
Effective serum osmolality of 320 mOsm/kg or greater. Most modern laboratories should be able to provide accurate readings for osmolality but for health professionals practicing in areas where osmolality cant be measured in lab, this formula for osmolality may be helpful:
Plasma Osmolality = 2[Na or serum sodium level] + 2[K or serum potassium level] + [Glucose] + [Urea]
Profound dehydration.
Serum pH greater than 7.30
Bicarbonate concentration greater than 15 mEq/L
Small ketonuria and absent-to-low ketonemia
Some alteration in consciousness
Management of hyperosmolar hyperglycemia requires vigorous rehydration and correction of blood glucose level.
If the patient presents in comatose state a multi sectoral approach is essential to help the patient. If underlying infections like cellulitis and pneumonia has been identified, treatment with antibiotics is vital. Certain drugs used in heart failure and hypertension like calcium channel blockers and diuretics may also precipitate hyperosmolar state and therefore must be reviewed by cardiologists and endocrinologists. Since children with Type I Diabetes are prone to develop this condition, pediatricians must always be kept informed.
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