Most

common complication of insulin treatment & sulphonylureas.

Symptoms: Rapid onset Sympathetic

overactivity develop when blood glucose levels fall < 3.0mmol/L Hunger, sweating, pallor, tachycardia If untreated, symptoms of neuroglycopenia develop Personality changes, fits, occasionally hemiparesis, then coma

Blood glucose confirms diagnosis but treatment should begin immediately Rapidly absorbed carbohydrate (sugary drinks) given orally If unconscious, give IV dextrose (50mL of 50% dextrose trough a large-gauge needle), followed by a flush of normal saline. IM glucagon (1mg) acts rapidly by mobilizing hepatic glycogen, useful when IV access is difficult Oral glucose is given when the patient revives, to replenish glycogen stores

 Severe

hyperglycemia occurs without significant ketosis Commonly occurs in uncontrolled Type 2 Diabetes Precipitated by:
Consumption of glucose-rich fluid Concomitant medication (thiazide, steroid) Intercurrent illness
Endogenous

insulin levels are reduced but still sufficient to inhibit hepatic ketogenesis, whereas glucose production is unrestrained.

 History

is longer and patient is often old Profound dehydration (secondary to osmotic diuresis), glucose >35mmol/L Decreased level of consciousness, due to elevated plasma osmolality (>340mosmol/kg)

 Rehydrate

with ~9L of 0.9% saline IVI over

48hours Replace K+ when urine starts to flow Wait 1h before using insulin. 1unit/h is enough Hyperosmolar state predispose to stroke, MI or arterial thrombosis prophylactic subcutaneous heparin is given.

 Prognosis: Mortality

rate: 20-30% because of the advanced age of the patients and frequency of intercurrent illness