Management of acute complications of diabetes mellitus
Diabetic ketoacidosis and hyperosmolar hyperglycemic state are the two commonest complications of type 1 and type 2 diabetes mellitus respectively
Diabetic ketoacidosis
Results from relative or absolute insulin deficiency combined with counterregulatory hormone excess (glucagon, catecholamines, cortisol, and growth hormone).
This results in gluconeogenesis, glycogenolysis, and ketone body formation in the liver ensues.
For more detailed understanding of the pathogenesis of DKA refer http://www.medscape.com
https://emedicine.medscape.com/article/118361-overview
Symptoms of DKA
- Fast breathing or kussmaul breathing due to severe acidosis
- polyuria due to osmotic diuresis due to glycosuria
- Intravascular volume loss due to polyuria and vomiting
- Nausea and Vomiting due to ketones
- Abdominal pain that may mimic acute abdomen
- Polydipsia due to dehydration
Physical Findings in DKA
- Tachycardia due to dehydration
- Dehydration/hypotension
- Tachypnea/Kussmaul respirations/respiratory distress
- Abdominal tenderness (may resemble acute pancreatitis or surgical abdomen)
- Lethargy/obtundation/cerebral edema/possibly coma
Laboratory findings
- Confirm diagnosis –high plasma glucose, positive serum ketones,
- Urinalysis –glycosuria and ketonuria
- Acid-base status— metabolic acidosis with low pH, low HCO3–, and low PCO2.
- Renal function –acute kidney injury with creatinine, and urea elevated and a low urine output
- Serum electrolytes -K+, Na+, Mg2+, Cl–, bicarbonate, phosphate.In most cases potassium is low and even when serum potassium is normal there is depletion of total body potassium
Treatment of DKA
Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH <7.00 or unconscious
Correction of electrolyte abnormalities and fluid replacement take precedence over insulin administration.Insulin administration prior to this can lead to life threatening arrhythmias and shock
- Fluid management
- Fluid-dka patients have 5-11l deficit typically about 100mls/kg due to osmotic diuresis of hyperglycaemia,vomiting and hyperventilation may also contribute
- Give 2–3 L of 0.9% saline over first 1–3 h as 1L start,1l in 30 minutes , 1L in 3ours then 1L every 6 hours
- Change to 5% glucose and 0.45% saline when sugars fall below (11.2 mmol/L)
- (ii) Insulin therapy
- Administer short-acting insulin: IV (0.1 units/kg) bolus , then 0.1 units/kg per hour by continuous IV infusion
- If levels don’t fall by 5.5mmol/l then double dose and if they fall by more than 8.3,mmol/l reduce by half but never stop.
- Minimum glucose concentration in 24hours should be 11.2mmol/l .If it falls below this then use 5% dextrose. And insulin level kept at 1unit per hour to support insulinisation and inhibit ketogenesis
- Potassium replacement
Even when serum potassium is normal or elevated in patients with DKA have total body potassium depletion of 500-700 millimoles
- If the initial serum potassium is <3.3 mmol/L do not administer insulin until the level is corrected.
- If the initial serum potassium is >5.2 mmol/L (5.2 meq/L), do not supplement K+ until the potassium is corrected through fluid administration
- use 10 meq/h when plasma K+ < 5.0–5.2 meq/L (or 20–30 meq/L of infusion fluid)
- administer 40meq/h when plasma K+ < 3.5 meq/L
- If k between 3. 5-5 then use 20meq/h
Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1–4 h.
Continue above management until patient is stable, glucose goal is 8.3–13.9 mmol/L and acidosis has resolved
Administer long-acting insulin as soon as the patient starts eating.
Hyperglycemic Hyperosmolar State (HHS)
- Affects elderly individual with type 2 DM
- Characterized by severe hyperglycemia, dehydration, and coma in the absence of significant acidosis or ketonemia
- Common conditions that precipitates or triggers HHS include myocardial infarction or stroke Sepsis,pneumonia,urinary tract infections or other serious infections .Always look out for them.
- history of polyuria, weight loss, and diminished oral intake that culminates in mental confusion, lethargy, or coma
- Examination reveals profound dehydration and hyperosmolality and reveals hypotension, tachycardia, and altered mental status
Management of HHS
- Fluid-
- The total amount of fluid loss is around 6-9 liters, much more than in DKA
- Administer normal saline 1-2 liter in the first 2hours to expand ECF.
- Patients need 6-8 liters (100-200ml/kg) of fluid in the first 12hours, adjust this depending on patients’ clinical status. Patients with cardiovascular disease need less aggressive rehydration
- Electrolytes
- Potassium replacement just like in DKA with total loss of about 5meq/kg
- Insulin
- More sensitive with great risk of hypoglycemia from insulin and rapid urine diuresis
- No loading dose use 1-5units of insulin hourly. If infusion not available use intravenous bolus of 10-30 units every 2-4hourly
- Normalization of glucose is not the primary goal of treatment just like in DKA.
- Insulin therapy-unlike DKA patients with HHS have relative insulin deficiency thus their total insulin requirement is less than in DKA
Chronic complications of Diabetes mellitus
- icrovascular complications
- Diabetic retinopathy, a leading cause of blindness worldwide. Other ophthalmic complications include : cataract,macular edema,glaucoma. Regular comprehensive eye checks are recommended for all diabetics.
- Neuropathy-sensory and motor poly and or mono neuropathy, autonomic neuropathy.
- Diabetic nephropathy leading to kidney failure
- Macrovascular complications
- Coronary heart disease
- Peripheral arterial disease
- Cerebrovascular disease/stroke
Treatment goals of diabetes mellitus
- HBA1C-less than 7 %
- Preprandial capillary plasma glucose-3.9–7.2 mmol/L
- Blood pressure <130/80
- Lipids
- Low-density lipoprotein <2.6 mmol/L
- High-density lipoprotein >1 mmol/L in men >1.3 mmol/L) in women
- Triglycerides <1.7 mmol/L (150 mg/dL)
- Nutritional education
- Exercise-150 minutes/week
- Weight loss
- Diabetic education-self monitoring, insulin use etc.
Insulin therapy
Only recommended treatment for T1DM and add on therapy in T2DM.
Different preparations exist
- Short acting
- Aspart 3-4hours
- Lispro
- Regular insulin duration of action 4-6 hours
- Long acting -duration of action of about 24 hours
- Determir
- Glargine
- Degludec
- glargine
- Insulin combination-duration 10-16 hours
- 70/30–70% NPH, 30% regular (mixtard insulin
- 50/50–50% protamine lispro, 50% lispro
For type 1 DM the insulin requirements are 0.4-1i.u/kg per day with 50% given as basal insulin .To determine pre-meal rapid acting insulin requirements use the following formula
- insulin to carbohydrate ratio which is about 1 unit of insulin for every 10-15g of carbohydrate
- to this add correctional or supplemental insulin based on each individual's pre-prandial blood glucose at 1unit for every 2.7mmol/l above target
Use basal insulin e.g glargine or detemir or glargine and pre-meal short acting insulin e.g insulin lispro,aspart etc
For type 2 DM a bedtime basal long acting insulin e.g detemir maybe used in addition to oral hypoglycemic agents.Also pre-mixed insulin e.g 70/30 NPH 70:30% regular maybe used
Surgical therapies
Whole pancreatic transplantation simultaneously performed during kidney transplant can normalize blood sugar in type 1 DM
Pancreatic islet cell transplantation has shown benefit but is largely investigational
Metabolic (bariatric surgery) for obese individuals with BMI ) greater than 30 has shown considerable promise with resolution of diabetes or marked reduction in insulin requirements.
