Treatment of Acute Conditions Related to Diabetes Mellitus!

 TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS

1. Coronary Heart Disease
2. Dyslipidemia
3. Hypertension
4. HIV and AIDS
5. Antipsychotic Therapy
6. Hypoglycemia
7. Diabetic Ketoacidosis (DKA)
8. Hyperosmolar Hyperglycemic state
9. Retinopathy
10. Neuropathy
11. Foot Ulcers 

The Acute Complications Include:

1. Hypoglycemia
2. DKA
3. Hyperosmolar Hyperglycemic state

6. HYPOGLYCEMIA

 "Hypoglycemia or low blood sugar can be defined clinically as a blood glucose level of less than 50mg/dL".

Signs:

• Individuals with DM can experience symptoms of hypoglycemia at varying blood glucose levels.
• Patients who have regular blood glucose levels as high as 300-400mg/dL may experience symptoms of hypoglycemia when blood glucose levels are lowered to the middle to upper mg/dL range.

Most people whose blood glucose levels are controlled adequately may experience symptoms when levels fall below 70mg/dL.

Symptoms:

• Shakiness
• Sweating
• Fatigue
• Hunger
• Headaches
• Confusion

*Patients experiencing symptoms of hypoglycemia should check their blood glucose levels, consume 15g of carbohydrate, and wait 10-15 minutes for symptom resolution*.

Etiology:

• Delayed or inadequate amounts of food intake, especially carbohydrates
• Excess dose of medications (such as sulfonylureas and insulin)
• Exercising when insulin doses are reaching peak effects.
• Inadequately adjusted drug therapy in patients with impaired renal or hepatic patients

Treatment:

Acceptable treatments may include; 

• small box of raisins, 4oz of orange juice, 8oz of skim milk oz three to six glucose tablets.
• In patients receiving an a-glucosidase inhibitor in combination with a sulfonylurea or Insulin, hypoglycemia should be treated with glucose tablet or skim milk owing to the mechanism of action of the a-glucosidase inhibitors.
• For patients whose blood glucose levels have dropped below 50mg/dL as much as 30g of carbohydrate may be necessary to raise blood glucose levels adequately.
• For patients with hypoglycemia experiencing a loss of consciousness, a glucagon emergency kit should be administered by the IV or SC route.

7.DIABETIC KETOACIDOSIS (DKA)

"Diabetic Ketoacidosis is a reversible but potentially life-threatening medical emergency that results from a relative or absolute deficiency in insulin"

Pathophysiology:

• Without insulin, the body cannot use glucose as an energy source and must obtain energy via lipolysis. This process produces ketones and leads to acidosis.

Risk Factors:

• Although DKA occurs in young patients with T1 DM on initial presentation, it can occur in adults as well.
• Often precipitating factors include:                                                                                      Infection, Omission or inadequate administration of insulin.

Signs and Symptoms:

Symptoms develop within 1 day or so and commonly include;

• fruity or acetone breath
• Nausea
• Vomiting
• Dehydration
• Polydipsia
• Polyuria
• Deep and rapid breathing

Diagnostic Criteria:

• Hallmark diagnostic criteria for DKA include hyperglycemia (greater than 250mg/dL), Ketosis (anion gap greater than 12mEq/L), and Acidosis (arterial pH less than or equal to 7.3).
• Typical fluid deficit is 5-7L or more and major deficits of serum sodium and potassium are common.
• The severity of DKA depends on the magnitude of the decrease in arterial pH, serum bicarbonate levels, and the mental state rather than the magnitude of the hyperglycemia.

Treatment:

• Treatment goals of DKA consists of reversing the underlying metabolic abnormalities, rehydrating the patient, and normalizing the serum glucose.
• Fluid replacement with normal saline at 1-1.5 L/hr. for the first hour is recommended to rehydrate the patient and to ensure the kidneys are perfused.
• Potassium and other electrolytes are supplements as indicated by laboratory assessment.
• The use of sodium bicarbonate in DKA is controversial and generally only recommended when the pH is less than or equal to 7 after 1hr of hydration.
• Regular insulin at 0.1 unit/kg/h by continuous IV infusion is the preferred treatment in DKA to regain metabolic control rapidly.
• When plasma glucose values drop below 250mg/dL, dextrose 5% should be added to the IV fluids.
• During the recovery period, it is recommended to continue administering insulin and to allow patients to eat as soon as possible.
• Dietary carbohydrates combined with insulin assist in the clearance of ketones.

8.HYPEROSMOLAR HYPERGLYCEMIC STATE

"Hyperosmolar hyperglycemic state (HHS) is a life-threatening condition similar to DKA that also arises from inadequate insulin, but HHS occurs primarily in older patients with T2DM".

• DKA and HHS differ in that HHS lacks the lipolysis, ketonemia and acidosis associated with DKA.
• Patients with hyperglycemia and dehydration lasting several days to weeks are at the greatest risk of developing HHS.

Etiology:

• Infection, silent myocardial infarction, cerebrovascular accident, mesenteric ischemia, acute pancreatitis, and the use of medications such as steroids, thiazide diuretics, calcium channel blockers, propranolol, and phenytoin are known precipitating cause of HHS.

Diagnostic Criteria:

• Two main diagnostic criteria for HHS are a plasma glucose value of greater than 600mg/dL and a serum osmolarity of greater than 320mOsm/kg.

Treatment:

• The treatment of HHS consists of aggressive rehydration, correction of electrolyte imbalance and continuous insulin infusion to normalize serum glucose. However, in patients with HHS, blood glucose levels should be reduced gradually to minimize the risk of cerebral edema.