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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Insulin treatment causes movement of potassium ions into cells which causes hypokalaemia. Potassium should therefore be checked prior to commencing each infusionofIVfluid.Theresultisthenusedtodeterminehowmuchpotassiumchloride (KCl)shouldbeaddedtothesubsequentinfusion.
Potassiumlevel>5.5mmol/L:noKClinnextinfusion Potassiumlevel3.5–5mmol/L:40mmol/LKCl Potassiumlevel<3.5mmol/L:40mmol/LKClandrequestseniorreview.
Fixedrateinsulininfusion
Prescribeaninsulininfusionof50unitsofshort-actinginsulin,e.g.Actrapid®,mixedwith50mL
0.9%saline Theinfusionrateshouldstartat0.1 units/kg/hourandshould commenceafterthefirstbagofIV fluidshasbegun Continueanylong-actinginsulinthatthepatientisusuallyprescribed.
IV fluids and insulin may be given through the same cannula, butonly ifit is a large-bore cannulaanditisattachedtoasplitconnectorwithone-wayvalves.
Monitoring
General
RegularroutineobservationsandmonitoringofGCSscore ContinuouscardiacmonitoringifthepatienthassevereDKA(Box4.2).
Bloods
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CheckABGandketonelevelshourly:
Aimforbloodketonestofallbyatleast0.5mmol/L/hour(ifketonemonitoringisunavailable, aim for bicarbonate level to rise by 3.0mmol/L/hour or blood glucose levels to fall by
3.0mmol/L/hour).Ifthisisnotachieved,callforseniorhelpandconsiderincreasingtheFRII by1mmol/hour.
If the CBG machine is unable to calculate a precise measurement (because glucose is >27mmol/L),thenusetheglucosevaluefroma serumsampleprocessedinthelaboratory or bloodgasmachine.
If the glucose level is <14mmol/L, add a 10% glucose infusion at a rate of 125ml/hour. ContinuethesalineinfusionandFRII;however,considerreducingtherateoftheFRIIto0.05 units/kg/hourtoreducetheriskofhypokalaemiaandhypoglycaemia.
VBGafter1hour,after2hours,andthen2-hourly(recordpH,potassium,andbicarbonatelevels) duringthefirst6hours,andthenagainat12hours.
Examination
Reassessfluidstatusafter12hoursofIVfluids,orsoonerifanyclinicalconcern.Aimforaurine outputofatleast0.5mL/kg/hour.
Ifthepatientisincontinentoranuric,considercatheterizationtoensureaccuratefluidbalance assessment.
Treatmentafterstabilization
EnsurepatientsreceiveprophylacticLMWH(seeChapter99)unlesscontraindicated.
Resolution
DKAhasresolvedwhen:
Bloodketonesare<0.6mmol/LAND VenouspHis>7.3ORbicarbonateis>18mmol/L.
Ifthepatientisnoteatingordrinking,continueIVfluidsandswitchtoavariablerateinsulin infusion(VRII) If theyareeatinganddrinking regular meals,restartthepatient’sinsulin regimen(orstarta new regimen under the guidance of an inpatient diabetes team if newly diagnosed). Give short-actinginsulinjustbeforeameal,andstoptheFRII1hourafterthemeal.
All patients with DKA should be reviewed by the local diabetes team within 24 hours of
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admission.Considerationshouldbegiventochanginginsulindosagesfollowingresolutionof DKA. Allpatientsshould bedischargedwithacareplanwhichshouldbecopied tothe GP. This should includespecificadvice abouthowtomanagediabetesduring illness,follow-up arrangements,andcontactdetailsforthediabetesteamtohelpavoidfurtheradmissions.
Specialconsiderations
Complications
Potassiumimbalances
HypokalaemiaandhyperkalaemiaarepotentialcausesofmortalityinpatientswithDKA.
Hypoglycaemia
There is a smallrisk of hypoglycaemia(<4mmol/L) during the treatmentof DKA. This canbeassociatedwithcardiacarrhythmias,braininjury,anddeath.
Cerebraloedema
This is a rare complication in children and young adults and is associated with rapid administrationoflargevolumesofIVfluids.
Pulmonaryoedema
Thismayoccurinpatientsatriskoffluidoverloadandreflectstheneedforcautionwith fluidreplacement.
Furtherreading
1. Wass J, Owen K (eds) (2014). Diabetic hyperglycaemic emergencies. In: Oxford Handbook of Endocrinology and Diabetes, 3rd ed (pp. 683–4). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199644438.003.0013
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Chapter16
Hypercalcaemia
Guideline: Society for Endocrinology Endocrine Emergency Guidance
(Emergency management of acute hypercalcaemia in adult patients):
https://ec.bioscientifica.com/view/journals/ec/5/5/G9.xml
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hypercalcaemia is defined as a serum concentration of calcium >2.60mmol/L. Approximately50% of extracellular calcium is bound to albumin, therefore totalserum calciumlevelsrequirecorrectingforserumalbuminconcentration.
Calcium homeostasis is regulated through intestinalabsorption, bone resorption, and renaltubularreabsorption.Theseareprimarilycontrolledbyparathyroidhormone(PTH) and vitamin D. Hypercalcaemia results from an abnormality of one or more of these processes.
Hypercalcaemiacanbeclassifiedaccordingtoseverity(Table16.1).
Table16.1Severityofhypercalcaemia
Severity Adjustedserumcalcium(mmol/L)
Mild 2.6–3.0
Moderate 3.0–3.5
Severe >3.5
CausesofhypercalcaemiaarelistedinTable16.2.
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Table16.2Causesofhypercalcaemia
Primary hyperparathyroidism
a
Adenoma(80–85%) Hyperplasia Carcinoma—rare Multipleendocrineneoplasia
Malignancy
a
PTH-relatedpeptidesecretedbysolidtumours(80%) Osteoclastactivatingfactors Metastaticbonedestruction
Granulomatousdisorders
Sarcoidosis Granulomatosiswithpolyangiitis TB Histoplasmosis
Drugs
Thiazidediuretics Lithium VitaminAtoxicity VitaminDtoxicity Theophyllinetoxicity
Highboneturnover
Paget’sdiseasewithimmobilization Thyrotoxicosis Immobilization
Renalfailureassociated
Tertiaryhyperparathyroidism Aluminiumtoxicity Rhabdomyolysis (biphasic with initial hypocalcaemia and then hypercalcaemia candevelop)
Familial
Familialhypocalciurichypercalcaemia
Miscellaneous
Adrenalinsufficiency Milk-alkalisyndrome Phaeochromocytoma
a
Mostcommoncausesofhypercalcaemia,accountingfor90%ofcases.
Diagnosis
History
Obtainathoroughhistory,includingfamilyhistoryandsignsof underlyingmalignancy. Patientswithacutehypercalcaemiamaypresentwiththefollowing:
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Polyuriaandpolydipsia Mooddisturbances:depression,memoryloss,confusion,coma Abdominalpainduetonephrolithiasis,nephrocalcinosisorconstipation Muscleweaknessandbonepain Proximalmyopathy Nausea Symptomsduetoarrhythmias,e.g.palpitations.
A wayto remember thetypical symptomsofhypercalcaemiais ‘painful bones,renal stones, abdominalgroans,andpsychicmoans’.
Patients may have symptoms from the underlying cause of their hypercalcaemia, e.g. nightsweats,weightloss,oranorexiasecondarytoanunderlyingmalignancy.
They may also have symptoms from conditions that may develop as a result of hypercalcaemia(Box16.1).
Box16.1Conditionsthatmaydevelopasaresultofhypercalcaemia
Pancreatitis Pepticulceration Cardiomyopathy Kidneydisease.
Examination
UsetheABCDEapproachtoexaminepatients(Table16.3).
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Table16.3FindingssuggestiveofacutehypercalcaemiainanABCDEexamination
C
Hypertension Dehydration
D
Confusion Hyporeflexia Hypotonia Paresis Coma
E
Itching Conjunctivitis Renalangletenderness(stones) Cornealcalcification Fragility/pathologicalfractures
Investigations
Bedside
ECG:shortenedQTinterval,prolongedPRinterval,andarrhythmias.
Bloods
Calcium(Box16.2),phosphate,PTH,vitaminD,U&E,andLFT(includingalbumin).
Box16.2Interpretationofbloods
Avoidprolongedtourniquetapplicationandrepeatserumcalciumtoconfirmdiagnosis HighcalciumandhighPTH = primaryortertiaryhyperparathyroidism HighcalciumandlowPTH = malignancyorotherlesscommoncauses.
Imaging
ChestX-raymayrevealunderlyingmalignancyorgranulomatousdisease Ifevidenceofprimaryhyperparathyroidismispresent,furtherneckimaging(suchasultrasoundor sestamibiscanning)isindicated.
Management
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Severe, symptomatichypercalcaemiaislife-threatening.Theinitialacutemanagementof hypercalcaemiafocusesonrehydrationandstoppinganycausativemedication.Diagnosis of the underlyingdiseaseis essentialinordertoreverse themechanismof the impaired calciumbalance.
Acutemanagement
Vigorousrehydration
Sincemostpatientswithhypercalcaemiaare dehydrated,4–6Lof0.9%salineshouldbe infused in 24 hours if there are no contraindications, e.g. congestive cardiac failure. Volume expansion with saline enhances urinary calcium excretion because calcium is coupled to sodium in the kidneys. After 24hours of fluid resuscitation, recheck serum calciumlevelbeforeconsideringadministeringbisphosphonates.
Monitorfluidbalanceintheelderlyandpatientswithrenalimpairmentandconsideringgiving furosemideifappropriateforoverloadonly.
Intravenousbisphosphonates
These agents inhibit osteoclast activity; however, they may take 72 hours to reach full therapeuticeffect.Commenceoncevolumerepleteifcalciumisstillelevatedandmonitor serum calcium response. Occasionally a second dose is needed. Rarely, hypocalcaemia maydevelopifthepatientisvitaminDdeficient.
Zoledronicacid4mgover15minutesOR Pamidronate30–90mgat20mg/hourOR Ibandronicacid2–4mg.
Second-linetreatments
Glucocorticoids
Inhibit 1,25OHD production and are useful in hypercalcaemia caused by vitamin D intoxication, granulomatous disorders, and lymphoma. Prednisolone given at a dose of 40mgdailyisusuallyeffectivewithin72hours.
Denosumab
Understrictspecialistsupervision.
Calcitonin
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Works predominantly by inhibiting osteoclast bone resorption, while it also enhances calciumandphosphateurinaryexcretion.
Renaldialysis
May be indicated in severe renal failure and is a very effective method of treating hypercalcaemiashouldtheabove-mentionedmeasuresnotbesuccessful.
Parathyroidectomy
Occasionally considered in the acute presentation of primary hyperparathyroidism, if resistanttopharmacologicalmeasures.
Furtherreading
1. NICE Clinical Knowledge Summaries (2019). Hypercalcaemia. Available at:
https://cks.nice.org.uk/topics/hypercalcaemia/
2. Levi R, Silver J (2011).Hypercalcaemia.In: Wass JAH,StewartPM, AmielSA,Davies MJ (eds)
OxfordTextbook of Endocrinology and Diabetes, 2nd ed (pp. 642–52). Oxford: Oxford University Press.Availableat:https://doi.org/10.1093/med/9780199235292.003.0411
https://t.me/med1917
Chapter17
Hyperglycaemia
Guidelines:JointBritishDiabetesSocietiesforInpatientCare(Management
of hyperglycaemia and steroid (glucocorticoid) therapy, 2021):
https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_08_Steroids_DM_Guideline_FINAL_28052021.pdf
Joint British Diabetes Societies for Inpatient Care (The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients, 2014):
https://abcd.care/sites/abcd.care/files/resources/JBDS_IP_VRIII.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hyperglycaemiaisdefinedaseitherfastingserumglucose>7mmol/L,orrandomglucose >11.1mmol/L. It is a common occurrence in diabetic and non-diabetic patients (stress hyperglycaemia), and is associated with prolonged hospital stays, worse outcomes, and increased mortality. In diabetic patients, hyperglycaemia can develop into the life­threateningemergenciesofDKA(seeChapter15)andHHS(seeChapter18).
Diagnosis
CBGmeasurementispartofroutinenursingcare.Historyandexaminationareimportant inidentifyingthecauseandcontextofthehyperglycaemia,andestablishinghow unwell thepatientis.
History
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