Block 3: Acute Complications Associated with Diabetes

Question 1

What are the acute complications with diabetes?

Answer 1

1. Hypoglycemia
2. Hyperglycemia (DKA, Hyperosmolar hyperglycemic state)

Question 2

What is hypoglycemia?

Classifications

Answer 2

Low blood glucose < 70 mg/dl:
Level 1: Blood glucose 54-70 mg/dl
Level 2: Blood glucose < 54 mg/dl
Level 3: A severe hypoglycemic event with altered mental status requiring assistance

Question 3

What sx of hypoglycemia are masked by beta-blockers?

Answer 3

Everything but sweating

Question 4

What are the sx of first stage hypoglycemia?

Answer 4

ANS sx:
1. Nervous/anxiety
2. Sweating
3. Hunger
4. N
5. Angina
6. Irritability
7. Tachycardia

Question 5

What are the sx of second stage hypoglycemia?

Answer 5

CNS sx:
1. Weakness/fatigue
2. Mental impairment
3. Dizziness
4. HA
5. Drowsiness
6. Loss of coordination
7. Coma, seizure, death

Question 5

What are the causes of hypoglycemia?

Answer 5

1. Missed or delayed meals
2. Vomiting
3. Decreased carbohydrate intake
4. Increased physical activity
5. Menstruation (decreased progesterone) -> decreased insulin
6. Inaccurate blood glucose monitoring results -> too much insulin

Question 6

Who are at risk for asymtomatic hypoglycemia?

Answer 6

1. Elderly
2. Advanced neuropathy
3. Beta-blockers

Question 7

What are the tx of mild hypoglycemia?

Answer 7

Test blood glucose if possible:
* Low blood glucose < 70 mg/dl

If low treat with 15 grams of carbohydrates; repeat if needed:
* 3 glucose tablets
* OTC glucose gel
* ½ cup of fruit juice or regular soda
* 1 cup of milk
* 5 pieces of hard candy
* 3 tsp. of table sugar
* 1 TBS of honey

Avoid chocolate, contains fat that slows the absorbtion of carbs

Question 8

What do you do after administering 15 g of carbs?

Answer 8

1. Recheck BG 15 minutes after tx
2. If blood glucose is still low, or if symptoms persist, retreat
3. After blood glucose >70 mg/dl patient should eat small carbohydrate snack to prevent recurrent event

Question 9

What is the tx for severe hypoglycemia?

Answer 9

Usually needs assistance from someone for treatment:
1. Dextrose 50% IV 50 ml (25 gm)
2. Glucagon Dry Powder (NS): 3 mg spray in 1 nostril
2. Glucagon Injection Kit or Autoinjector (IV, IM or SC)
* Adults: 1 mg
* Children 0.25-0.5 mg

Question 10

Whta is hyperglycemia?

Answer 10

Blood glucose > 130 mg/dl fasting
Blood glucose > 180 mg/dl within 2 hours after meals

Question 11

What are the sx of hyperglycemia?

Answer 11

1. Extreme thirst
2. Hunger
3. Dry skin
4. Frequent urination
5. Blurred vision
6. Drosiness
7. N

Question 12

What are the causes of hyperglycemia?

Answer 12

1. Food
2. Emotional stress
3. Physical stress
4. Lack of normal exercise
5. Inadequate diabetes medication regimen
6. Use of improperly stored insulin

Question 13

What are the general guidelines for mild hyperglycemai tx?

Answer 13

1. ALter med regimen
2. Drink plenty of sugar-free fluids
3. Lifestyle mod: dietary changes, increase physical activity

Question 14

What do you do if a patient comes and you’re unsure if they are Hypo- or Hyperglycemia?

Answer 14

Assume the patient has
HYPOglycemia

Question 15

What is the somogyi effect?

Answer 15

Rebound hyperglycemia:
Bedtime glucose is normal -> Low glucose during 2-3AM -> hyperglycemia in AM

Question 16

What are the nocturnal sx of somogyi? Tx?

Answer 16

1. Nightmares
2. Sweating
3. Hunger
4. Headache

Need to decrease insulin dose to prevent nocturnal HYPOglycemia

Question 17

What is dawn phenomenon?

Answer 17

Morning HYPERglycemia:
Bedtime glucose is normal -> Normal glucose during 2-3AM -> hyperglycemia in AM

Question 18

Sx of dawn phenomenon? Tx?

Answer 18

May see small increase in glucose levels in the early morning (4 to 8 AM)

Need to increase insulin dose

Question 19

What are the complications of severe hyperglycemia?

Answer 19

1. DKA
2. Hyperosmolar Hyperglycemic Non-ketotic Syndrome (HNS)

Both Can Be Life Threatening

Question 20

What is the cause of DKA?

Answer 20

T1DM mostly:
Severe insulin deficiency -> body can’t use glucose -> FA used as fuel -> ketones build up in the body

Question 21

What are the sx of DKA?

Answer 21

1. Hyperglycemia (not extremely high)
2. 3 Ps
3. HA, fatigue
4. Dehydration
5. Acetone breath -> Kussmaul breathing
6. Ketonuria
7. N/V

Question 22

What are the clinical tx of DKA?

Answer 22

IV fluids: replace fluids is required
Insulin: Correction of HYPERglycemia and ketosis with insulin will be required (slowly); continue until ketones are (-) and anion gap closes
Potassium: correction of any electrolyte imbalances, especially K and P may be needed, K will likely be needed
Bicarb: Possible contraindication; use only if pH < 6.9

Question 23

How do you monitor DKA?

Answer 23

Plasma glucose falls more rapidly than ketones:
* Do NOT stop insulin until reversal of ketosis occurs.

Use the pH and anion gap to assess response, not glucose and ketones:
* Normal anion gap: 8-12 mEq/L
* A high anion gap indicates that there is loss of HCO3- without a concurrent increase in Cl- to compensate for increased metabolic acidosis

Question 24

How do you calculate anion gap?

Answer 24

Anion gap = cations-anions
Anion gap= ([Na+] - [Cl- + HCO3-])

Question 25

What is HNS?

Answer 25

T2DM mostly:
The amount of insulin produced and/or medications are not adequate for the body’s needs form prolonged hyperglycemia

Stress

Question 26

What is sx of HHS?

Answer 26

1. Severe hyperglycemia
2. 3 Ps
3. Severe dehydration
4. Weakness
5. Leg cramps
6. Impaired vision
7. Mental changes
8. HYPOtension
9. Tachycardia

Question 27

What is the tx of HHS?

Answer 27

IV fluids: replace of fluids required
Insulin:Correction of HYPERglycemia with insulin will be required
Potassium: Correction of any electrolyte imbalances, especially K and Phos may be needed; K will likely be needed