Problems In The Managment Of Diabetes And Its Complications

Question 0

Diabetic ketoacidosis

Answer 0

Hyperglycaemia and metabolic acidosis
Causes:
Omission or reduction in insulin does
Illness/infection
Emotional upset
Menstruation/pregnancy
Rare syndromes of insulin release
Process:
Decreased plasma insulting, increased plasma glucose, glucagon predominates
Increased amino acid release from muscle and FFA and glycerol release from adipose
Used by liver to synthesis glucose and ketones
Ketones-> metabolic acidosis-> CNS depression->diabetic coma
Glucose-> osmotic diuresis-> circulating failure, renal failure! low cerebral blood flow
Treatment:
Medical emergency
Replace fluid, electrolytes-> K and HCO replacement
iv insuli
Treat cause

Question 1

Hypoglycaemia

Answer 1

Type 1-> Insulin overdoes, excessive exercise, inadequate CHO
Type 2-> sulphanylureas, hepatic or renal disease! some drugs
Symptoms:
Palpitations, tremor, sweating, anxiety-> counter regulatory CNS
Loss of concentration, slurred speech, behaviour/mood changes, seizures, loss of consciousness-> glucose deficiency in the brain-> neuroglycopenia/neuroglucopenia
Treatment:
Conscious-> sugary drink/food
10-15 mins recovery then snack for sustained carbs
Unconscious->emergency
Glucose gel
Glucagon injections

Question 2

Hyperosmolar hyperglycaemic state

Answer 2

Happens in type 2
Blood glucose >40mmol 
Severe hyperglycaemia without Ketosis
Managed the same as Ketosis but without the insulin 
Causes similar to Ketosis 
Illness 
Not taking medication 
Severe dehydration increases osmolarity

Question 3

Complications statistics

Answer 3

Life expectancy reduced by 20y t1 10 years t2
80% will die of CV disease
X2-3 increase risk of stroke and heart attack
Leading cause of blindness
1000 start dialysis each year

Question 4

Long term complications, retinopathy

Answer 4

Micro vascular
Most common cause of blindness under 65
95% of patients after 20 years of diabetes
Classification:
Background-> micro aneurysms, haemorrhages, exudates
Pre-Proliferative-> damage caused by increased glucose->ischamia
Proliferative-> new blood vessels grow in response to damage
Maculopathy-> blood leaks-> realise of chemicals-> retina comes away-> blind
Treated with lasers, can cause some vision loss

Question 5

Long term complications, nephropathy

Answer 5

25% of diabetics
1:3 on dialysis
High cv risk
Angiopathy of capillaries of glomeruli, glomerulscerlosis
Early-> microalbuminuria 5-10 years after diagnosis
Later-> protienuria, increase BP, decreased GFR 10 years
Advanced-> end stage renal disease
ACEi help limit nephropathy

Question 6

Long term complications, neuropathy

Answer 6

Microvascular 
25% 
May effect cranial, autonomic, peripheral nervous system 
Mainly in feet-> increased risk of foot ulcers 
Symptoms:
Loss of sensation 
Tingling
Shooting pains
Cramps
Causalgia

Question 7

Long term complications, metabolic syndrome

Answer 7

Macrovascular
Accelerated atherosclerosis
T1-> bad glycemic control
T2-> glycemic control, genetic predisposition, metabolic syndrome
Cluster of cv risk factors associated with insulin resistance:
Dyslipidaemia-> increased LDL decreased HDL increased triglycerides
Hypertension
Coagulation abnormalities

Question 8

Long term complications, Ischaemic heart disease

Answer 8

Developes prematurely
Leading causes of death in diabetes
Myocardial infact, increased risk of complications
Need for vigorous management of risk factors
Hyoercholesterolaemia, hypertension

Question 9

Long term complications, stroke

Answer 9

Macrovascualar
Up to 10 fold increase in younger patients
More likely to be fatal
Transient Ischaemic acidosis less likely
Cause of chronic disability

Question 10

Long term complications, peripheral vascular disease

Answer 10

Intermittent claudication
Ulceration
Risk of gangrene-> amputation

Question 11

Management of risk factors

Answer 11

Good glycemic control
Control of hypertension 
Systolic <80
Control of dyslipidaemia, statins, fibrates
Use anti platelet drugs