Endo E1- Complications

What are acute complications of DM?

Hypoglycemia, DKA, Hyperosmolar Nonketotic State

How do chronic complications of DM manifest?

microvascular and macrovascular problems

Microvascular or Macrovascular:

Basement membrane thickening → diabetic retinopathy, nephropathy, neuropathy

Microvascular

Microvascular or Macrovascular:

Accelerated atherosclerosis

Macrovascular

Level 1 Hypoglycemia BG level (glucose alert value)

Glucose ≤70 mg/dL

Level 2 Hypoglycemia BG level (clinically significant)

Glucose <54 mg/dL

Which level of hypoglycemia:

Sufficiently low for treatment with fast-acting carbs and dose adjustment of glucose-lowering therapy

Level 1 (glucose alert value)

Which level of hypoglycemia:

Sufficiently low to indicate serious, clinically important hypoglycemia

Level 2 (clinically significant)

Which level of hypoglycemia:

Hypoglycemia associated with severe cognitive impairment, requiring external assistance for recovery

Level 3 (severe)

When do most hypoglycemic episodes occur?

At night

What can cause hypoglycemic episodes in diabetic patients?

Change in insulin/hypoglycemic medication dose, Small or missed meals, Strenuous exercise

What are sx of hypoglycemia?

tachycardia, slurred speech, blurred vision, confusion, light headed, trembling, pallor, sweating

What are complications of hypoglycemic episodes?

Coma, Seizure, Permanent neuro damage, MI, Stroke

What is the preferred treatment for a conscious individual with BG ≤70 mg/dL?

15-20g glucose q15min until BG >100

What should be prescribed for patients at increased risk of clinically significant hypoglycemia? (<54 mg/dL)

Glucagon

What is the initial tx for a hypoglycemic emergency?

bolus 25mL of 50% glucose followed by continuous glucose infusion

Does DKA mainly occur in T1DM or T2DM patients?

T1DM

DKA is an increase in serum ketones >____

5 mEq/L

DKA BG level is >_____

250 mg/dL

DKA blood pH is <_____ with a high anion gap

7.2

DKA bicarb level is ≤_____

18 mEq/L

What is DKA?

acute state of severe uncontrolled diabetes that requires emergency tx w/ insulin and IV fluids

In DKA, what is used as an alternative energy source resulting in accumulation of ketones & ketoacids?

Free fatty acids

What are Kussmaul respirations?

Rapid, deep, labored breathing pattern that occurs as a result of respiratory compensation in patients with DKA

What produces the characteristic fruity breath odor of ketotic patients?

Acetone

What are the effects of DKA on renal/urine systems?

Significant glycosuria & Increased water loss due to osmotic diuresis

How much water is typically lost in DKA?

~6 L

What is the most characteristic electrolyte disturbance in DKA patients?

Total body potassium loss

In DKA, serum potassium levels are falsely (increased/decreased)

Increased

What is the leading cause of bacterial infections precipitating DKA?

Klebsiella pneumoniae

What is used for initial correction of fluid loss in DKA?

Isotonic sodium chloride or lactated Ringer solution

At what rate should IV fluids be administered for initial correction of fluid loss in DKA?

1 L over first 30 min

1 L over second hour

1 L over following 2 hours

1 L every 4 hours

What is the optimal rate of glucose decline when managing DKA?

100 mg/dL/hr

You should not allow BG to fall below what level during the first 4-5 hours of DKA treatment?

200 mg/dL

What complication can occur if hyperglycemia & hyperosmolarity is corrected too quickly in DKA?

Cerebral edema

DKA treatment: if K level is > 6, administer ___ mEq/h of potassium chloride

NONE

DKA treatment: if K level is 4.5-6, administer ___ mEq/h of potassium chloride

10

DKA treatment: if K level is 3-4.5, administer ___ mEq/h of potassium chloride

20

When treating DKA you should hold off starting insulin therapy until when?

potassium replacement is underway in order to avoid dysrhythmias

When treating DKA, when should sodium bicarb be infused to correct acid-base imbalance?

Only if decompensated acidosis is life-threatening

What are complications of DKA?

Cerebral edema, Cardiac dysrhythmia, Pulmonary edema, Myocardial injury

What 3 symptoms characterize HNS?

Impaired mental status, Elevated plasma osmolality, Marked hyperglycemia

Does HNS mainly occur in T1DM or T2DM patients?

T2DM

HNS criteria:

Serum osmolality >_______

320 mOsm/kg

HNS criteria:

Plasma glucose >_______

600 mg/dL

HNS criteria:

pH ______ or higher

7.3

HNS criteria:

Bicarb > ______

15 mEq/L

HNS criteria:

Profound _____________

Dehydration

HNS criteria:

Absence of ______________

Severe ketosis

The degree of hyperglycemia in HNS is usually extreme w/ many pts presenting with what glucose level?

> 1,000 mg/dL

What is the first line therapy for patients with HNS?

Rapid & aggressive IV volume replacement

What complication may occur in a patient with HNS if fluid replacement is not done prior to insulin therapy?

Circulatory collapse

What is the major contributor to blindness caused by diabetic retinopathy?

Macular edema

Is retinopathy a microvascular or macrovascular complication of DM?

Microvascular

In diabetic retinopathy, the abnormal growth of friable blood vessels on the retina produce what?

Microaneurysms

*may rupture → flame or blot hemorrhages

What is macular edema characterized by?

retinal thickening and presence of hard exudates near the fovea

What technique can be used as a noninvasive means of treating microvascular retinal disease?

Laser photocoagulation

What is the MCC of kidney failure in the US?

Diabetic nephropathy

What are the main focuses of managing diabetic nephropathy?

Control hyperglycemia, HTN, and keep pts on reduced protein diet

Is nephropathy a microvascular or macrovascular complication of DM?

Microvascular

Formal classification criteria of diabetic nephropathy:

>300 mg/day of albumin confirmed on 2 occasions at least 3 months apart

Progressive GFR decline

Elevated arterial BP

Mildly decreased GFR

60-89

Moderately decreased GFR

30-59

Severely decreased GFR

15-29

GFR in kidney failure

<15

Is neuropathy a microvascular or macrovascular complication of DM?

Microvascular

What is diabetic nephropathy characterized by?

angiopathy of capillaries in the kidney glomeruli → progessive albuminuria, dec GFR, HTN

What is diabetic neuropathy characterized by?

progressive loss of nerve fibers

What contributes to diabetic neuropathy?

oxidative stress, excessive neuronal intracellular glucose, glycation end product disruption of cellular metabolism

How does diabetic neuropathy present?

stocking/glove distribution, ascending, symmetric

What is the leading cause of nontraumatic lower limb amputations?

DM

Which nerves are affected first in diabetic neuropathy?

long nerves d/t disproportionate delay in nerve conduction

What does the treatment for diabetic neuropathy begin with?

Glycemic control & regular surveillance

What medications can be given for pain control of diabetic neuropathy?

TCAs, Gabapentin or pregabalin, Cymbalta, Topical lidocaine, Capsaicin

What preventive therapy is recommended by the ADA for diabetic patients who are at high risk for CV events?

Low dose ASA

What is the goal BP for patients with no CV risk factors for treatment of macrovascular complications?

< 140/90

What is the goal BP for patients with CV risk factors for treatment of macrovascular complications?

< 130/80

What is the goal LDL for patients with no CV risk factors for treatment of macrovascular complications?

< 100 mg/dL

What is the goal LDL for patients with CV risk factors for treatment of macrovascular complications?

< 70 mg/dL