Diabetes mellitus (main): Difference between revisions

Revision as of 03:42, 10 November 2018

Growing in worldwide prevalence
Results from either inability of the body to release insulin from the pancreas or a resistance against the actions of insulin

Patients with diabetes may be asymptomatic
Acute symptoms may range from those of nonketotic hyperglycemia (e.g. polyuria, polydipsia) to DKA (ill appearance, acetone breath, Kussmaul's breathing, somnolence)

Corticosteroids (most common drug-induced cause)
Thiazide diuretics
Atypical antipsychotics (olanzapine, clozapine, quetiapine)
Beta-blockers (especially non-selective)
Phenytoin
Tacrolimus, cyclosporine (transplant patients)
Protease inhibitors (HIV antiretrovirals)
Catecholamines (epinephrine, norepinephrine infusions)
SGLT-2 inhibitors (paradoxical DKA with euglycemia)
Total parenteral nutrition (TPN)
Dextrose-containing IV fluids (iatrogenic)
Niacin
Pentamidine (initially hyperglycemia, then hypoglycemia from beta-cell destruction)

Sepsis / critical illness (stress hyperglycemia — very common in the ED)
Trauma / major surgery / burns
Acute coronary syndrome / myocardial infarction
Stroke (especially hemorrhagic)
Pancreatitis (both a cause and consequence)
Shock (any etiology)
Pain (catecholamine surge)
Seizure (postictal)
Physiologic stress alone rarely causes glucose >200 mg/dL in non-diabetics; glucose >200 in a "stress response" should prompt evaluation for undiagnosed diabetes or prediabetes

Renal failure (chronic kidney disease, acute kidney injury — impaired insulin clearance AND insulin resistance)
Cirrhosis / hepatic failure (impaired glycogenolysis regulation)
Pregnancy (gestational diabetes, steroid administration for fetal lung maturity)
Parenteral nutrition (TPN, dextrose-containing fluids)
Post-transplant diabetes (immunosuppressants)

These are associated conditions that may be present alongside hyperglycemia but do not themselves cause elevated glucose:

Diabetes mellitus itself is not normally a diagnosis sought in the emergency department (i.e. via A1C)
Hyperglycemia can be found on laboratory testing
- Asymptomatic patients do not necessarily require additional testing
- Symptomatic or potentially symptomatic patients require additional testing
  - Check CBC, BMP, and ketones (if sick see additionally DKA workup)
  - UA is only necessary if you are ruling out urinary infection or do not have serum ketones available and are using it as a screening mechanism

May consider IV hydration or IV insulin administered in the ED
All patients with diabetes newly diagnosed in the ED will require reliable follow-up for education and blood sugar monitoring
May consider discharging patient with prescription for metformin, starting dose is 850 mg daily

@@ Line 11: / Line 11: @@
 ==Evaluation==
-Workup based on provider level of suspicion for emergent process such as DKA, HHS, sepsis
+*Diabetes mellitus itself is not normally a diagnosis sought in the emergency department (i.e. via A1C)
+*Hyperglycemia can be found on laboratory testing
-*In asymptomatic patient may consider UA to check for ketones
+**Asymptomatic patients do not necessarily require additional testing
-*Sick patients will require CBC, BMP, blood gas, EKG, additional tests at provider discretion
+**Symptomatic or potentially symptomatic patients require additional testing
+***Check CBC, BMP, and ketones (if sick see additionally [[DKA]] workup)
+***UA is only necessary if you are ruling out urinary infection or do not have serum ketones available and are using it as a screening mechanism
 ==Management==