DM-Complications Flashcards
EuglycemicDKA must be considered in
Pregnancy
Precipitating factors
Infection (pneumonia / UTI / gastroenteritis / sepsis)
• Infarction (cerebral, coronary, mesenteric, peripheral)
• Pancreatitis
• Drugs (cocaine)
• Pregnancy ( EuglycemicDKA must be considered)
• Omission or inadequate insulin
• Mental health disorders
Pathophysiology of DKA
counterregulatory hormone excess (glucagon, catecholamines,cortisol, and growth hormone)
Gluconeogenesis+Glycogenolysis
Hyperglycaemia
Laboratory abnormalities in DKA
hyperglycemia (serum glucose > 250 mg/dL)
• Ketosis
• Metabolic acidosis (serum bicarbonate <15–18 mmol/L)
Arterial pH usually ranges between 6.8 and 7.3
• Serum potassium at presentation may be mildly elevated
• Total-body stores of potassium, sodium, chloride, phosphorus, and
magnesium are reduced in DKA
• Leukocytosis, Hypertriglyceridemia, Hyperamylasemia
• Ketone body: β-hydroxybutyrate, acetoacetate.
Administer long-acting insulin as soon as patient is eating. Allow for a 2- to 4-h
overlap in insulin infusion and SC long-acting insulin injection.
DKA treatment
Salin or ringer lactate
change to 5% glucose and 0.45% saline or lactated Ringer’s when blood
glucose reaches 250 mg/dL
Administer short-acting regular insulin,
• Then continuous IV infusion
• increase two- to three fold if no response by 2–4 h
If the initial serum potassium is <3.3 mmol/L (3.3 meq/L), do not administer
insulin
Subcutaneous insulin may be used in uncomplicated, mild-moderate DKA with close monitoring.
. Replace K+:
• If initial serum potassium is >5.2 mmol/L (5.2 meq/L), do not supplement K+
Despite a bicarbonate deficit, bicarbonate replacement is not usually necessary.
• just In the presence of severe acidosis (arterial pH <7.0);
Continue above until patient is stable, glucose goal (150–
200 mg/dL), and acidosis is resolved. Insulin infusion may be decreased.
Administer long-acting insulin as soon as patient is eating. Allow for a 2- to 4-h
overlap in insulin infusion and SC long-acting insulin injection
HHS=Hyperosmolar hyperglycaemia state
elderly individual with type 2 DM,
with a several-week history of polyuria, weight loss, and diminished oral intake that
culminates in mental confusion, lethargy, or coma.
A debilitating condition (prior stroke or dementia) or social situation
• Profound dehydration > hyperosmolality,
hypotension, tachycardia,
confusion,
Pathophysiology (Relative insulin deficiency and inadequate fluid intake).
The marked hyperglycemia (plasma glucose may be > 1000 mg/dL)
• Hyperosmolality (>350 mOsm/L),
The measured serum sodium may be normal or slightly low despite the marked hyperglycemia.
• In contrast to DKA, acidosis and ketonemia are absent or mild.
**HHS has a substantially higher mortality rate than DKA **
HHS Treatment
Fluid replacement should initially stabilize the hemodynamic status of the patient
(1–3 L of 0.9% normal saline over the first 2–3 h).
• The calculated free water deficit (which can be as great as 9–10 L) should be
reversed over the next 1–2 days (200–300 mL/h of hypotonic solution).
Management of hospitalized DM patients
The target range in the perioperative period should be 80–180 mg/dL.
either an insulin infusion or SC insulin.
1/Insulin infusions are preferred in the ICU or in a clinically unstable setting
2/In patients who are not critically ill or not in the ICU, basal or
“scheduled” insulin is provided by SC,
Insulin infusion is the preferred for managing type1 DM over a prolonged (several hours) perioperative period or whenserious concurrent illness is present (regular insulin).
• If the diagnostic or surgical procedure is brief (<4 h), a reduced dose of
SC insulin may suffice with short-acting bolus insulin
Individuals with type 2 DM can be managed with either an insulin
infusion or SC long-acting insulin (20–50% reduction) plus preprandial,
short-acting insulin.
• Oral glucose-lowering agents should be discontinued upon admission (or
up to a week prior to planned admission for SGLT2 inhibitors).
• Moreover, these oral agents may be dangerous if the patient is fasting
(e.g., hypoglycemia with sulfonylureas,
Euglycemic DKA with SGLT2 inhibitors)
or at risk for declining kidney function due to, for example,radiographic contrast media or unstable CHF
(lactic acidosis with metformin).
TPN
TEN
DM TPN or TEN greatly increases insulin requirements.
• In addition, individuals not previously known to have DM
may become hyperglycemic during TPN or TEN and require insulin
treatment.
• For TPN, IV insulin infusion is the preferred treatment for hyperglycemia.
steroid-induced diabetes.
If new-onset hyperglycemia remains during chronic treatment with
supraphysiologic doses of glucocorticoid (>5 mg of prednisone or
equivalent), the DM may be called “steroid-induced diabetes.”
• Most pronounced in the postprandial period
If the FPG is near the normal range, oral diabetes agents (e.g., sulfonylureas, metformin)
may be sufficient to reduce hyperglycemia.
If the FPG is > 200 mg/dL oral agents are usually not efficacious, and insulin therapy is
required.
DIABETES MANAGEMENT IN OLDER ADULTS
In an individual with complex/poor health or cognitive impairment, an HbA1c goal of <8.0–8.5% would be reasonable.
Periproductive issues
Pregnancy is associated with marked insulin resistance; the increased
insulin requirements often precipitate DM and lead to the diagnosis of
gestational diabetes mellitus (GDM).
• Glucose, which at high levels is a teratogen to the developing fetus,
readily crosses the placenta, but insulin does not.
• Hyperglycemia from the maternal circulation may stimulate insulin
secretion in the fetus. The anabolic and growth effects of insulin may
result in macrosomia.
Screening for glucose intolerance: between weeks 24 and 28 of pregnancy in
women not known to have diabetes.
• Oral glucose-lowering agents are not approved for use during pregnancy.
• Individuals who develop GDM are at marked increased risk for developing type
2 DM in the future
• Children of women with GDM appear to be at risk for obesity and glucose
intolerance and have an increased risk of diabetes beginning in the later stages
of adolescence.
Intensive insulin therapy and near-normalization of the HbA1c (<6.5%)
are essential for individuals with existing DM who are planning pregnancy.
• The most crucial period of glycemic control is soon after fertilization.
• Maintenance of the HbA1c <6.0–6.5% reduces the incidence and severity
of fetal macrosomia and neonatal hypoglycemia related to fetal
hyperinsulinism at delivery driven by elevated maternal glucose pre-delivery .
DM Complications
Diabetes-associated microvascular complications usually do not appear until the second decade of hyperglycemia.
• In contrast, diabetes-associated CHD risk, related in part to insulin resistance and its
resultant dyslipidemeia, may develop before hyperglycemia is established.
The microvascular (retinopathy, neuropathy, nephropathy )complications of both type 1 and type 2 DM
Result from chronic hyperglycemia.
…………..and …………..also play important roles in macrovascular complications.
(CHD, peripheral arterial disease [PAD], cerebrovascular disease).
dyslipidemia and hypertension
strict……………. control significantly reduced both macro- and microvascular complications
blood pressure
ADA recommends blood pressure control <130/80 mmHg for individuals with high
cardiovascular risk and <140/90 mmHg for individuals with lower cardiovascular risk.
despite long-standing DM, some individuals never develop retinopathy or nephropathy,
suggesting a genetic susceptibility for developing particular complications.
The reduction of cellular glucose entry in certain tissues such as myocardium and renal
tubular epithelium through inhibition of the……………..may contribute to the reduction in CHD events and renoprotective effects.
sodium glucose co-transporter-2 (SGLT-2)
