Diabetes - Complications Flashcards
What is hypoglycaemia? What are the main causes?
hypoglycaemia is defined as low blood glucose levels
- occurs when blood glucose falls <5mmol/L
leads to suppressed insulin secretion, increased catecholamine secretions and stimulation of glucagon, cortisol and growth hormone
is mainly caused as a side effect of insulin treatment or sulphonylureas but also missed meals, overdoes/mis-timing of insulin, renal or hepatic impairment, weight loss
What are the symptoms of hypoglycaemia?
can be asymptomatic or symptomatic
symptomatic
autonomic - shaking, sweating, anxiety, dizziness, hunger, increased heart rate/palpitations, impaired vision, fatigue, headache, irritability
neuroglycopaenic - confusion, drowsiness, slurred speech, atypical behaviour
severe cases - reduced consciousness, coma
What masks the signs of hypoglycaemia?
beta blockers
anxiety - generalise anxiety disorder
How is hypoglycaemia treated?
if conscious and able to swallow
- give glucose orally as liquid or granulated sugar
when blood glucose is > 4 mmol/L
- give a snack providing sustained availability of carbohydrate (sandwich)
if unconscious or shows now response to glucose given
- give glucagon either via intravenous injection or infusion
- give 100ml of dextrose 10%
What is diabetics ketoacidosis (DKA)?
results from lack of insulin (undiagnosed DM, other illness or interruption of insulin therapy) leading to
- hyperglycaemia, >11 mmol/L
- increased lipolysis and hepatic gluconeogenesis (caused increased diuresis and dehydration)
- release free fatty acids (FFAs)
- conversion into ketone bodies
- acidosis, bicarbonate <15 mmol/L and/or venous pH <7.3
ketone bodies are found in urine (ketonuria)
- > 3 mmol/L
What are the symptoms of DKA?
dehydration
- sunken eyes, reduced tissue turgor, dry tongue, low blood pressure
deep rapid breathing
- kussmaul breathing
fruity/sweet smelling breath (due to ketone bodies presence)
disturbance of consciousness
low body temperature
abdominal pain
nausea and vomiting
polyuria, nocturia
polydipsia
fatigue
anorexia
How can DKA be investigated?
blood glucose levels - >20 mmol/L
plasma ketones
urine dip tests for glycosuria and ketonuria
arterial blood gases for metabolic acidosis
urea and creatinine - increased due to dehydration
total low potassium (osmotic diuresis) but often raised due to lack of insulin
low serum bicarbonate
How can DKA be managed?
IV Fluid resuscitation
fixed rate IV insulin (0.1unit/kg/hr)
- to correct hyperglycaemia and ketonaemia
potassium replacement
- must check for whole body potassium depletion in DKA
= as insulin typically causes cellular uptake
treat underlying cause
- infection, interruption of insulin therapy
VTE prophylaxis
- low molecular weight heparins = dalteparin (not in renal impairment), enoxaparin
- fondaparinux
- heparin (unfractionated) (used in renal impairment)
Monitor blood glucose, VBG, electrolytes
What is hyperosmolar hyperglycaemic state (HHS)?
What are the signs of HHS?
occurs in T2DM
- involves extremely high blood glucose levels (is lower in DKA)
- more common in the elderly (unlike in DKA)
- develops over a long period of time (unlike DKA which is sudden)
hyperglycaemia, >20 mmol/L
pH > 7.3 (non-acidic/ no acidosis)
minimal or negative ketonaemia (no ketoacidosis)
profound volume depletion
How can HHS be managed?
check/calculate serum osmolality
2Na + glucose + urea
IV fluids with/without potassium replacement
do not give insulin unless
- blood glucose stops falling or significant ketonaemia
VTE prophylaxis
What are complications associated with diabetes?
vascular
- microvascular = retinopathy (leading to blindness), nephropathy, neuropathy
- macrovascular = cerebrovascular disease (risk of stroke), cardiovascular disease (risk of myocardial infarction), peripheral vascular disease (poor circulation to limbs)
How can retinopathy be managed?
annual retinal screening / monitoring using digital retinal photography
tight glycaemic control
blood pressure control
hyperlipidaemia management
proliferative retinopathy
- Laser photocoagulation
- Vascular endothelial growth factor inhibitors (Bevacizumab)
- Vitrectomy
How can nephropathy be managed?
monitor renal function and albuminuria
- albumin:creatine ratio (ACR)
tight blood glucose control
blood pressure control
ACE inhibitor
- if there are no contra-indications, all diabetic patients with nephropathy causing proteinuria or with established microalbuminuria should be treated with an ACE inhibitor or an ARB even if the blood pressure is normal
low protein diet
lipid control
How can neuropathy be managed?
patient education
- e.g. correct shoe fitting
annual foot review
– inspect, check pulses, monofilament, tuning fork and reflexes
manage neuropathic pain
- Duloxetine, Amitriptyline, Pregabalin, Gabapentin
Manage ulcers
- Treat infections
- Debridement
- Specialist referral to podiatry
How can macrovascular complications be managed?
Optimise glycaemic control
Patient education
- increase physical activity
- healthy diet
- weight loss
control other cardiovascular risk factors
- blood pressure control
- hyperlipidaemia management
- smoking cessation
- consider antiplatelet therapy
