Acute Complications of Diabetes Mellitus Dr Hasan Fahmawi

Acute Complications of Diabetes Mellitus • Dr. Hasan Fahmawi, MRCP(UK), FRCP(Edin).

DIABETIC KETOACIDOSIS • Acute complications of D. M. • DKA. • Hypoglycaemia. • Hyperglycaemic Hyperosmolar State (HHS)

DKA • Definition: it is a medical emergency, and remains a serious cause of morbidity, principally in type 1 diabetes. Mortality in the UK is 2%, which is caused by cerebral oedema, hypokalaemia, acute respiratory distress syndrome, and comorbid conditions such as acute MI, pneumonia and sepsis. In young patients with recurrent DKA, up to 20% they have psychological problems complicated by eating disorders. • Diagnosis: • 1 -Hyperketonaemia, 3 mmol/L, ketonuria more than +2 - urine sticks. • Hyperglycaemia, RBS 200 mg. • Metabolic acidosis, p. H less than 7. 3 arterial or venous blood, or venous bicarbonate less than 15 mmol/L.

• 50% of the fluid loss is intracellular, and occurs comparatively early with relatively few clinical manifestations. • The magnitude of the hyperglycaemia doesn’t correlate with the severity of ketoacidosis. • Type 1 diabetes in pregnancy is one situation where DKA can occur without blood glucose levels are especially high.

Clinical assessment

• In patient with infection there might be no fever, WBCs might be high without infection, serum amylase may be raised but rarely indicates coexisting pancreatitis. • Investigations • Blood for p. H, bicarbonates, RFT, electrolytes and glucose. (arterial or venous). • Urine or blood for ketones. • ECG. • Infection screen, CBC, blood and urine culture, CRP, chest X-Ray.

Severity

Management 1 - Admission to ICU or HDU. 2 - Diabetic team care. 3 - Particular care for high risk groups, old age, pregnants and those with heart or kidney disease or other serious complications. 4 - Fluid replacement • 5 -Insulin (rapid or short acting). • 6 -Electrolytes. Na and K. • 7 -Na bicarbonate?

Hypoglycaemia • It is uncommon in people without diabetes, but relatively frequent in diabetics, mainly due to insulin therapy and less frequently due to oral hypoglycaemic drugs. • In diabetics it occurs if blood sugar is less than 70 mg/dl

Symptoms, activation of sympathetic nervous system and neuroglycopenia.

Circumstances of hypoglycaemia

Hyperglycaemic hyperosmolar state (HHS) • It is a medical emergency which is characterized by hypovolaemia, hyperglycaemia (600 mg/dl) and hyperosmolality ( serum osmolality above 320 m. Osmol/kg ), without significant kaetonaemia (less than 3 mmol ) or acidosis ( p. H more than 7. 3 ), bicarbonate more than 15 mmol/L. • There is glycosuria leading to osmotic diuresis with loss of water, sodium, potassium and other electrolytes. • However it develops over days or weeks causing more profound hyperglycarmia and dehydration ( fluid loss may be 10 -12 L in a person weighing 100 kg ). • It is common in old age. Common precipitating factors are, infection MI, • CVA or drug therapy ( glucocorticoids ). Mortality is over 20%. • Poor prognostic signs are hypothermia, hypotension, tachy- or bradycardia, • severe hypernatraemia, Na over 160 mmol/L and serious co-morbidity.

• Plasma osmolality = 2(Na)+glucose +urea. • Normal value is 280 -296 m. Osm/L. • Above 340 consciousness is impaired.