Acute complications of Diabetes Mellitus

Acute complications of diabetes

1. Complications of diabetes Dr Abdul Wahab Mir FCPS (Medicine) FCPS (Nephrology) UHB (QEHB, UK)

2. Diabetic ketoacidosis

3. Definition DKA diagnostic criteria: Hyperglycemia (Glucose > 250mg/dl) Ketosis (Serum or Urine + ve for Ketones) Metabolic Acidosis ( pH < 7.3 or Sr. H2CO3 < 15mEq/L )

4. Precipitating Factor (5 I’s) Insulin Deficiency Infection Infarction Inflammation Intoxication ( alcohol,cocaine etc )

5. Pathophysiology Insulin Deficiency Glucose Uptake Proteolysis Lipolysis AA Glycerol Free Fatty Acids HYPERGLYCEMIA Gluconeogenesis Ketogenesis Glucogenolysis Osmotic Diuresis Dehydration Acidosis

6. Symptoms: Nausea / Vomiting Polydipsia / Polyuria Abdominal Pain Shortness of Breath

7. Physical Findings Tachycardia Dehydration Tachypnea ,sweet fruity odor, Kussmaul Breathing) Abdominal Tenderness Lethargy  Confusion  Coma (10%)

8. Lab Investigations BSR: > 250 mg/dl (350-900 mg/dl) Ketosis : Serum or Urine Ketone levels Sr. Electrolytes Hyperkalemia Slight Hyponatremia Hyperphosphotemia RFTs

9. ABG’s Acidosis, can be severe (pH 6.9-7.2) (Sr. H2CO3 5-15mEq/L) Infection Screen  CBC, Blood & Urine Culture, CXR, CRP

10. Management Fluid Replacement Insulin Therapy Potassium Replacement Bicarbonate Replacement Antibiotics Prophylactic Anticoagulation

11. Fluid Replacement 1L/ hr for 1 st 2 hrs , then 300-400 ml/hr. >5L in 8hrs  ARDS & Cerebral Edema When BSR < 250 mg/dl  switch to 5% dextrose maintain Sr. Glucose 250-300 mg/dl. Be cautious in elderly patients.

12. Insulin Therapy REGULAR Insulin IV infusion Regimen : Loading 0.1 U/kg IV Bolus, then 0.1 U/kg/ hr infusion. Goal of Therapy : a) to lower Glucose concentration 50-70 mg/dl/hr. b)correction of acidosis & anion gap

13. K+ Replacement No replacement in 1 st hr until K+ < 3mmol/L. Sr. K+ > 5mmol/L Sr. K+ 3.5-5mmol/L If K+ < 3.5mmol/L  No replacement Give 10mmol/ hr Give 20mmol/L  Check K+ every with IV Fluids 2 hrs

14. Bicarbonate Replacement Not recommended in routine use. pH < 6.9 pH 6.9-7.0 pH > 7.0 NaHCO3 (100mmol) NaHCO3 (50mmol) No HCO3 dil. in 400 ml H2O. dil. In 200 ml H2O. Infuse at 200 ml/ hr Infuse at 200 ml/ hr  Repeat until pH > 7.0 every 2 hr.  Monitor Serum K+

15. Complications Cerebral Edema Pulmonary edema Arrythmias Hypophosphotemia Thromboembolism Myocardial infarction hypoglycemia

16. Monitoring Mental Status Vital Signs Blood Glucose hourly Sr. K+ 2 hourly ABGs 4 hourly for 1 st 24 hrs. Once DKA Resolved Shift to SC insulin regimen 0.5 – 0.6 U/kg/day

17. Prevention Strategies Patient education for compliance to regimen. BSR & BSF monitoring. Home monitoring of Ketones. Sick-day management.

18. Hypoglycemia

19. Hypoglycemia Most common complication in insulin treated diabetic patients. Occurs when Blood Glucose levels falls to around 54 mg/dl (3mmol/L)

20. Symptoms Sympathetic Symptoms Tachycardia / Palpitations Sweating Tremulousness Parasympathetic Symptoms Nausea Hunger

21. Symptoms Neuroglycopenic Symptoms when Glucose levels fall to 50 mg/dl (2.8mmol/L) Irritability Confusion Blurred vision Headache Speaking Difficulty If fall further below 50 mg/dl Loss of consciousness Seizures

22. Predisposing factors Drugs Sulfonylureas Repaglinide Nateglenide Behavioral Issues Injecting too much insulin with high carb meal Alcohol on empty stomach Those who treats high Glucose levels aggressively.

23. Impairment of Counter Regulatory System :- Impaired Glucagon response Sympatho -adrenal response Cortisol Deficiency Complications of Diabetes which lead to Hypoglycemia:- Gastroparesis Autonomic Neuropathy End Stage Chronic Kidney disease

24. Treatment Carry Glucose tablets / juices. 15 gm of carbohydrates Glucagon emergency kit (1mg) increases glucose in blood by 36 mg/dl (2mmol) MedicAlert bracelet or card in wallet. In Hospital  50 ml of 50% Glucose by rapid IV Infusion. If IV access not available  1mg Glucagon IM

25. Glucagon emergency kit

26. HyperGlycemic HyperOsmolar State

27. HyperGlycemic HyperOsmolar State Criteria :- Hyperglycemia > 600 mg/dl Serum Osmolality > 310 mOsm /kg No Acidosis, pH > 7.3 Serum HCO3 > 15 mEq /L Normal Anion Gap (<14mEq/L)

28. Relative Insulin Deficiency Reduce glucose utilization Induce Hyperglucagonemia & Of muscle and liver inc. hepatic glucose output Massive Glucosuria Obligatory Water Loss (severe dehydration) Impairment of Kidney Function Limited Urinary Excretion of Glucose Hyperglycemia + Hyperosmolality Mental Confusion / Coma

29. Sign & Symptoms

30. Management Fluid Replacement:- 0.9 % N/S if hypotension & oliguria In all other cases 0.45 % saline is preferable for initial treatment. 4-6 L fluid in 1 st 8-10 hrs. End point of Fluid therapy is to restore urine output to 50ml/hr.

31. Insulin Therapy:- Maintain Glycemic level of 200-300 mg/dl. Infuse 0.05 U/kg/ hr to reduce blood glucose by 50-70 mg/dl/hr. K+:- If no CKD/Oliguria (risk for hyperkalemia). KCl (10mEq/L) can be added to initial fluids if Sr. K+ not elevated. Phosphate:- Sr. PO4 < 1mg/dl (0.32 mmol/L) during Insulin therapy  Give 3mmol/ hr

32. Complications Myocardial Infarction Stroke Pulmonary Embolism Mesenteric Vein Thrombosis Disseminated Intravascular Coagulation

33. Thank you for your patience 