ACUTE

COMPLICATIONS OF
DIABETES MELLITUS

ACUTE COMPLICATIONS
1) Diabetic ketoacidosis
2) Hypoglycemia

Diabetic
3) Hyperglycemic hyperosmolar state coma
4) Lactic acidosis

HYPOGLYCEMIA AND
LACTIC ACIDOSIS

Mona (2)

DEFINITION
A state of low plasma glucose(lower limit of fasting
plasma glucose concentration is normally 70mg/dL)
Can lead to serious complications and if not treated
well within time it can be fatal.

WHIPPLES TRIAD
Symptoms consistent with hypoglycaemia.
A low plasma glucose concentration measured
precisely.
Relief of symptoms after the plasma glucose level is
raised.
5

HYPOGLYCEMIA IN DIABETES
As a result of treatment of diabetes with oral hypoglycemic drugs
and insulin therapy.
Limits the treatment in following ways:
1) causes recurrent complications in Type 1 diabetes and
long standing Type 2 diabetes.
2) hypoglycaemia associated autonomic failure(HAAF)
3)difficulty in maintenance of a state of euglycemia over
the lifetime of a diabetic person.
It is more prevalent in people suffering from type 1 DM and insulin
requiring type 2 DM.
10

RISK FACTORS
Improper dosage, timing or type of insulin
Reduction in intake of glucose (after missed meals or at
midnight).
Increase glucose utilization (during exercise)
Increased sensitivity to insulin (with increased fitness,
weight loss etc)
Reduced glucose production (alcohol consumption)
Reduced elimination or clearance of insulin (renal failure)
11

12

HYPOGLYCEMIA WITHOUT
DIABETES
Endogenous Hyperinsulinism
Non beta cell tumors
Drugs
Critical illness
Hormone deficiencies

13

DRUGS
Insulin
Insulin secretagogues
Alcohol dependant hypoglycaemia
Others like ACE inhibitors, ARBs etc.

14

ENDOGENOUS
HYPERINSULINISM
Beta cell tumor- insulinoma.
Beta cell hypertrophy or hyperplasia.
Antibody to insulin or its receptors
Beta cell secretagogue like sulphonylurea
Ectopic insulin secretion.

15

CRITICAL ILLNESS
Hepatic failure
Renal failure
Cardiac failure
Sepsis

16

HORMONAL DEFICIENCY
Addisons disease
Growth hormone deficiency
Glucagon and epinephrine deficiency(combined)

17

NON BETA CELL TUMORS

Hepatomas
Carcinoids
Adreno cortical carcinoma

18

SPONTANEOUS
HYPOGLYCAEMIA
In diabetics due to non judicious use of insulin and
drugs like sulphonylurea.
In non diabetics usually asymptomatic.
Said to have happened if all three conditions of
Whipple triad is met.
Characterised by hypoglycaemia unawareness,
convulsions, abnormal behaviour etc.
19

20

HYPOGLYCAEMIC COMA
Mostly seen type 1 DM patients on insulin
replacement therapy
Factors like missing meals, excessive exercise can
lead to unconsciousness.
Can occur within 20 minutes to an hour of early
symptoms.
Can be associated with convulsions
Signs like pallor, rapid heart rate and excessive
sweating are observed

21

APPROACH TO THE PATIENT

DIAGNOSIS:
1)Recognition of the typical signs and symptoms
2)Establishment of Whipples triad
3)Measure plasma glucose(best time to measure is a
symptomatic episode)
4)Additionally measure plasma insulin, C-peptide,
proinsulin.
5)Establish the cause of hypoglycaemia
22

TREATMENT
1) If patient is conscious, administer oral glucose in the form
of fluids, candy or food.
2) A minimum dose of 20g is suggested.
3) If patient is unable to take glucose orally, IV regimen is
followed.
4) 25g of IV glucose administered followed by an infusion of
glucose with measurement of plasma glucose
concentration.
5) If IV glucose fails, SC or IM glucagon can be used(dose
being 1g in adults). This is especially in case of Type1 DM.
6) In case of sulphonylurea induced hypoglycaemia,

23

PREVENTION OF
RECURRENT
HYPOGLYCAEMIA
Establish the cause leading to hypoglycaemia
Causative drugs either replaced or doses are reduced
Critical illnesses to be treated
Deficient hormones to be replaced
Tumors to be controlled by radiotherapy,
chemotherapy or surgery
Frequent feeding, avoidance of fasting needed
For some patients uncooked starch at bedtime or an
overnight intragastric infusion of glucose may be

24

LACTIC ACIDOSIS
A state of metabolic acidosis due to accumulation of lactic
acid produced during metabolism.
Rarely occurs in diabetics with renal co-morbidity and on
oral anti-diabetic drug, Metformin, which impairs lactate
metabolism (type 2 lactic acidosis)
Defects in gluconeogenesis due to inborn error of
metabolism.
25

MANAGEMENT OF LACTIC
ACIDOSIS
1) Diagnosis of lactic acidosis is confirmed by measuring
plasma lactate which can be ten fold the normal value of
20 mg/dl.
2) In case of diabetes related lactic acidosis, history of
metformin intake.
3) Stop the drug or reduce dosage or adjust timings.
4) Resuscitation with IV fluids needed
5) Bicarbonate infusion is not preferred reserved only for
severe cases of acidosis
26

DIABETIC
KETOACIDOSIS

Upasna (4)

27

 Acute medical

emergency
Younger patients
Type 1 DM
Type 2 DM (rarely)

28

ETIOLOGY

Inadequate insulin
administration
Infection
Infarction
Drugs (cocaine)
Pregnancy

29

PATHOPHYSIOLOGY

30

31

In physiological pH,
ketone bodies exist as
acids

Hyperglycemia

Decrease alkali
reserve

Osmotic diuresis

Metabolic acidosis

Glycosuria

Dehydration
Hypovolemia
Hypotension
32

CLINICAL PRESENTATION
SYMPTOMS
Thirst & polyuria
Nausea & vomiting
Abdominal pain
Shortness of breath
Weakness
Weight loss
Infection/ Infarction

SIGNS
Dehydration
Tachycardia
Cold extremities & peripheral
cyanosis
Hypotension (postural or
supine)
Air hunger (Kussmaul
breathing)
Smell of acetone
Confusion, drowsiness, coma

33

INVESTIGATIONS
1) Serum glucose : >200 mg/dl
2) Serum bicarbonate : <15
mEq/L or Venous pH <7.3
3) Serum ketones : 3 mmol/L
and Urine ketones : more than
2+ on standard urine sticks

DIAGNOSI
S

4) Serum electrolytes
34

INVESTIGATIONS
5) Renal function : Serum creatinine, urine output
6) ECG
7) Infection screen: full blood count, blood and urine
culture, C-reactive protein, chest X-ray.

35

TREATMENT GOALS
1) Fluid resuscitation
2) Reversal of the acidosis and ketosis
3) Reduction in the plasma glucose concentration to
normal
4) Replenishment of electrolyte and volume losses
5) Identification the underlying cause

36

TREATMENT : 0 - 60
MINUTES

1) Commence 0.9% sodium chloride

)If systolic BP > 90 mmHg, give 1 L over 60 mins

)If systolic BP < 90 mmHg, give 500 mL over 1015
mins,
2) Commence insulin treatment
)50 U human soluble insulin in 50 mL 0.9% sodium
chloride infused intravenously at 0.1 U/kg body
weight/hr
)Continue with SC basal insulin analogue if usually

37

0 - 60 MINUTES
3) Perform further investigations
4) Establish monitoring schedule
)Hourly capillary blood glucose and ketone testing
)Venous bicarbonate and potassium after 1 and 2 hrs,
then every 2 hrs, Plasma electrolytes every 4 hrs
)Clinical monitoring of O2 saturation, pulse, BP,
respiratory rate and urine output every hour
5) Treat any precipitating cause
38

60 MINUTES 12 HOURS
1) IV infusion of 0.9% sodium chloride with potassium
chloride added
2) Add 10% glucose 125 mL/hr IV when glucose < 14
mmol/L
3) Be more cautious with fluid replacement in elderly,
young people, pregnant patients and those with
renal or heart failure.
4) If plasma sodium is > 155 mmol/L, 0.45% sodium
chloride may be used.

39

12 24 HOURS
1) Ketonaemia and acidosis should have resolved
(blood ketones < 0.3 mmol/L, venous bicarbonate
> 18 mmol/L).
2) If patient is not eating and drinking, continue IV
insulin infusion at lower rate of 23 U/kg/hr
3) Continue IV fluid replacement and biochemical
monitoring
4) If ketoacidosis has resolved and patient is able to
eat and drink, re-initiate SC insulin with advice
from diabetes team.

40

ADDITIONAL PROCEDURES
1) Catheterization
2) Central venous line if cardiovascular system
compromised, to allow fluid replacement to be
adjusted accurately also consider in elderly,
pregnant, renal or cardiac failure, other serious
comorbidities, severe DKA
3) Measure arterial blood gases and repeat chest X-ray
if O2 saturation < 92%
4) ECG monitoring in severe cases
41

OUTCOME AND
COMPLICATIONS
With appropriate therapy, the mortality rate of DKA is
low (<1%)
Related more to the underlying or precipitating event
Acute respiratory distress syndrome
Cerebral edema
Cardiac dysrhythmia
Pulmonary edema
42

PREVENTION
Patient education
During any illness, patients should
1) Frequently measure the capillary blood glucose
2) Measure urinary ketones when the serum glucose
is >300 mg/dL
3) Drink fluids to maintain hydration
4) Continue or increase insulin
5) Seek medical attention
43