5. Complications associated with diabetes

Question 1

Pathophysiology of diabetic ketoacidosis DKA:

what are the 3 main problems associated with DKA

Answer 1

ketoacidosis, dehydration, potassium imbalance

Question 2

Pathophysiology of diabetic ketoacidosis DKA:

why does ketoacidosis occur

Answer 2

inappropriately burn fats through liipolyiss
initially the kidneys produce bicarbonate to counteract the ketone acids in the blood
over time the ketone acid use up the bicarb and the blood starts to become acidic

Question 3

Pathophysiology of diabetic ketoacidosis DKA:

why does dehydration occur

Answer 3

hyperglaemia overwhelms the kidneys. and glucose starts being filtered into the uric

glucose in urine draws water out (osmotic diuresis)

causes patient to urinate a lot resulting in dehydration which then leads to thirst eg polydipsia

Question 4

Pathophysiology of diabetic ketoacidosis DKA:

why does it cause potassium imbalance

Answer 4

insulin normally drives potassium into cells

Serum potassium can be high or normal as the kidney continues to balance blood potassium with potassium excreted in urine

total body potassium however is low as no potassium is stored in cells

note that when insulin treatment starts pt can develop hypokalaemia and this can leaad to arrhythmias

Question 5

what internal changes does DKA cause

Answer 5

Hyperglycaemia
Dehydration
Ketosis
Metabolic acidosis (with a low bicarbonate)
Potassium imbalance

Question 6

how will a patient with DKA present

Answer 6

Polyuria
Polydipsia
Nausea and vomiting
Acetone smell to their breath
Dehydration and subsequent hypotension
Altered Consciousness
They may have symptoms of an underlying trigger (i.e. sepsis)

Question 7

how would you diagnose DKA

Answer 7

hyperglycaemia (ie blood glucose greater than 11)
ketosis (ie blood ketones greater than 3)
acidosis (ie Ph less than 7.3)

Question 8

How would you treat a DKA

hint the mnemonic is FIG-PICK

Answer 8

F- fluids (normal saline first and then 4 litres with added K+ over the next 12 hours)
I- insulin
G- glucose (monitor and add dextrose if below a certain level)

P- potassium
I- infection
C- chart fluid balance
K- ketones (monitor blood ketones or bicarb is ketone monitoring is not available)

Question 9

when you have treated the DKA what is it important to re establish

Answer 9

the patients normal subcutaneous insulin

Question 10

Name 3 common complications in relation to diabetes

Answer 10

diabetic retinopathy
kidney disease
diabetes foot

Question 11

how can capillary leakage of plasma into retina lead to sight loss

Answer 11

intra retinal haemorrhages and odema –> exudates ini the retina
if it is in the peripheral retina then it is non-sight threatening
if it is in the macula area then can lead to loss of central vision

Question 12

how can capillary occlusion lead to total blindness

Answer 12

retinal ischemia, new vessel formation, haemorrhage, and fibrosis and ultimately retinal detachment leading to glaucoma

Question 13

As well as retinal screening what can be injected into the vitrous

Answer 13

anti vascular endothelial growth factor (anti VEGF)

Question 14

in management of kidney disease what things would you want to measure
(leads to micro or macroproteinuria)

Answer 14

eGFR (this would decrease in kidney disease)

UACR (urea, albumin, creatinine ratio)

Question 15

in diabetic foot, what neuropathic pain sensations could they feel and what relieves their symptoms

Answer 15

a lot of sensations !
worse at night
eased by exercise or counter irritation

Question 16

in diabetic foot, why do ulcers occur

Answer 16

there is a loss of the protective sensation and so abnormal foot function

Question 17

what early signs can you see in a diabetic foot before an ulcer appears

Answer 17

areas of callus and retracted toes due to the neuropathy

Question 18

what other complications are assosicated with diabetic foot

Answer 18

can get infections which lead to septicaemia or impact on circulation so get local thrombosis and gangerinne of the toes

Question 19

what are the complications of diabetics in pregnancy and how can this be optimised

Answer 19

in 1st trimester can get congenital anomalies
in 2nd and 3rd trimester can get accelerated growth

pre-pregnancy blood glucose control and folate supplement

Question 20

which kind of diabetics have increased coronary heart disease mortality

Answer 20

T2

Question 21

Heart failure is more prevalent in which ethnic group

Answer 21

people from South Asian ethnic groups

but less common in black ethnic group

Question 22

In DKA why do patients present with hyperventilation

Answer 22

due to metabolic acidosis

Question 23

in DKA why do patients present with vomitting

Answer 23

ketosis + hyperglycaemic gastric statis

Question 24

why do T2 diabetics not tend to suffer from DKA but more just hyperosmolar hyperglycaemic state compared to type 1

Answer 24

only need a small amount of insulin to suppress lipolysis and ketogensis

T2 still produce some insulin whereas T1 produce next to none

Question 25

how can stress predicate DKA or HHS

Answer 25

increases the secretion of glucagon, catecholamines and cortisol which all oppose the effects of insulin

Question 26

What symptoms would you get if the patient is suffering from hypoglycaemia

Answer 26

adrenergic symptoms (sweating, trembling, hunger)
neuroglycopenia ie paratyhesia, blurred vision, confusion

Question 27

what would make someone more likely to have a hypo

Answer 27

alcohol excess
very young or very old 
long duration DM
recent severe hypo 
pregnant 
autonomic neopathy 
renal or hepatic impairment

Question 28

what other things can cause peripheral neuropathy and why

Answer 28

excessive alcohol drinking
vitamin B12 deficiency (due to the demyelination)
Under-active thyroid
presence of proteins in the blood

Question 29

What can be used in the management of neuropathy

Answer 29

ACEi or AT2I (keeps its microalbuminism in its early phase ie for renal protection)
Duoloxetine or gabapentin