DIABETES MELLITUS

COMPLICATIONS
Dr Saima Ambreen
Associate Professor, Internal Medicine,
Medical Unit 1, Holy Family Hospital, Rawalpindi.
Learning Outcomes
• Etiopathogenesis of diabetic emergencies
• Clinical features and investigations to confirm diagnosis and
complications
• Management plan of each emergency condition
CLINICAL SCENARIO:
• A 32-year-old male with type 1 diabetes since the age of 14 years was taken to
the emergency room because of drowsiness, fever, cough, diffuse abdominal
pain, and vomiting.
On examination he was tachypneic, pulse rate 104 beats per minute, respiratory
rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry
mucous membranes, poor skin turgor, and rales in the right lower chest. He was
slightly confused. Rapid hematology and biochemical tests showed hematocrit
48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose
450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl
(123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L and Cl− 110 mmol/L. Arterial pH
was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The
result of the strip for ketone bodies in urine was strongly positive. Urinalysis
showed glucose 800 mg/dl and specific gravity 1.030.
• What is your diagnosis?
 Core subject

COMPLICATIONS:
• MACROVASCULAR:
•
Myocardial ischemia/infarction
Transient ischemic attack (TIA), stroke
Claudication, ischemia

• MICROVASCULAR:
OCULAR (CATARACTS, RETINOPATHY, GLAUCOMA)
NEPHROPATHY
NEUROPATHY ( PERIPHERAL NEUROPATHY, AUTONOMIC NEUROPATHY)
• DKA
• HHS
• Hypoglycemia
Core subject
 Core subject

MACROVASCULAR COMPLICATIONS:

• Cardiovascular disease accounts for 70% of all deaths.

• Atherosclerosis in diabetic patients occurs earlier and is more extensive

and severe.

• Amplifies the effects of the other major cardiovascular risk factors:

smoking, hypertension and dyslipidaemia.
 Core subject

MACROVASCULAR COMPLICATIONS:
• PERIPHERAL VASCULAR DISEASE:

-Incidence of gangrene of the feet in patients with diabetes is 30 times that

in age-matched controls.
-ischemia of the lower extremities, erectile dysfunction, and intestinal angina
can occur.
- calculate ankle brachial index and stratify patients according to this index
for PAD.
-statins can be used.
- beta blocker are relatively contraindicated
 Core subject

MACROVASCULAR COMPLICATIONS:
• HYPERTENSION:
-target BP in DM is </=130/80
-drug of choice is ACEI for uncontrolled HTN & proteinuria in DM
unless contraindicated.

• CVD:
-Aspirin at a dose of 81–325 mg daily is effective in reducing
cardiovascular morbidity and mortality
-
 Core subject

MICROVASCULAR COMPLICATIONS:
• OCULAR COMPLICATIONS:
Cataracts:
-due to nonenzymatic glycosylation of lens, correlate with duration of
diabetes & severity of hyperglycemia.

• GLAUCOMA:
-Open angle glaucoma more common
 Core subject

MICROVASCULAR COMPLICATIONS:
• Retinopathy:

-Most common cause of blindness in adults aged 35-65 years.

-hyperglycemia causes endothelial dysfunction causing increased

vascular permeability, leading to characteristic exudates on retina
seen via fundoscopy & SLE.
 Vertical Integration

DM RETINOPATHY:
• BACKGROUND:
-microaneurysms(dots).
-blot hemorrhages (</=3),
-hard exudates ( collections of exudates lipid and proteins).
• PREPROLIFERATIVE:
-Deep/ dark cluster hemorrhages
-cotton wool spots/ soft exudates( ischemic infarcts of nerve fiber layer of
retina)
-venous beading/looping.
- more common in Type 1 DM
- Tx with laser photocoagulation.
 Vertical Integration

DM RETINOPATHY:
• PROLIFERATIVE:
-neovascularization, vitreous hemorrhage, fibrosis anterior to retinal disc
- more common in Type 1DM.
- urgent Tx with panretinal photocoagulation.

• MACULOPATHY:
- hard exudates & other background changes on macula
- more commona in Type 2 DM.

• TIP: if asymmetric DM retinopathy, suspect ocular ischemia.

Vertical Integration
Vertical Integration
 Core subject

DM NEPHROPATHY:
• initially manifested by albuminuria; subsequently, as kidney function
declines, Urea & Creatinine levels rise in blood.

• An albumin-creatinine ratio (ACR) in an early morning spot urine is

used to detect albuminuria.

• In DM, ACR > 2.5 mg/mmol in men & 3.5 mg/mmol in women is
clinically significant.
 Core subject

DM NEPHROPATHY:
• At least two early morning spot urine collections over a 3- to 6-month
period should be abnormal before a diagnosis of microalbuminuria is
justified.

• Short-term hyperglycemia, exercise, UTI, heart failure, and acute

febrile illness can cause transient albuminuria.

• Drug of choice for albuminuria in DM is ACEI.

 Core subject

DM NEUROPATHY:
• 1. PERIPHERAL NEUROPATHY:
A. DISTAL SYMMETRIC POLYNEUROPATHY:
-stocking-glove pattern.
-due to an axonal neuropathic process.
-Longer nerves are especially vulnerable.
-Both motor and sensory nerve conduction is delayed in the
peripheral nerves.
-Sensory involvement usually occurs first and is generally bilateral,
symmetric.
-examined with a 5.07 Semmes-Weinstein filament.
 Core subject

DM NEUROPATHY:
• - calluses and ulcerations in the high-pressure areas.
- predisposes to development of Charcot arthropathy.
- for neuropathic pain: Gabapentin, Amitriptyline.

• B. ISOLATED PERIPHERAL NEUROPATHY:

-sudden onset with subsequent recovery of all or most of the function.
-attributed to vascular ischemia or traumatic damage.
-Cranial and femoral nerves are commonly involved, and motor
abnormalities predominate.
 Core subject

DM NEUROPATHY:
• 2. AUTONOMIC NEUROPATHY:
-affects many diverse visceral functions including:
blood pressure,
pulse,
GI activity,
bladder function,
and erectile dysfunction.
-GI: nausea, vomiting, postprandial fullness, reflux or dysphagia,
constipation or diarrhea (or both), and fecal incontinence.
 Core subject

DM NEUROPATHY:
• - for gastroparesis: metoclopramide, erythromycin.
• - for diarrhea: loperamide + antibiotic ( rifaximin, metronidazole,
amoxicillin/clavulanate, ciprofloxacin, or doxycycline.)
• - for Incomplete emptying of the bladder: Bethanechol
• - for orthostatic hypotension: Use of Jobst fitted stockings, tilting the
head of the bed+ fludrocortisone, midodrine can be used.
• - for erectile dysfunction: Sildenafil (Viagra), vardenafil (Levitra)
Vertical Integration
 Core subject

DIABETIC KETO ACIDOSIS:

• Excess of ketones in the body of a previously diagnosed or an undiagnosed
diabetic patient, causing metabolic acidosis is called diabetic ketoacidosis.

• PRECIPITATING FACTORS: missed insulin dose, infection, MI.

• DIAGNOSTIC CRITERIA:
-BSR> 250 mg/dL (13.9 mmol/L).
-Metabolic acidosis with blood pH < 7.3; serum bicarbonate less than 15
mEq/L.
-Serum positive for ketones.
 Core subject
DIABETIC KETO ACIDOSIS:
 Core subject

DIABETIC KETO ACIDOSIS:

• MANAGEMENT:
- fluid replacement- around 6 lit, isotonic saline is used usually.
- insulin: at 0.1 units/kg/hr, if BSR<250, start 5% D/W.
- Correct hypokalemia
-LMWH to prevent DVT.

• COMPLICATIONS:
- cerebral edema( due to rapid correction of fluid)
-Thromboembolism
-ARDS
-ARF
-gastric stasis
 Core subject
HYPEROSMOLAR HYPERGLYCEMIC
STATE(HHS)
• DIAGNOSIS:

-bsr> 600 mg/dL (33.3 mmol/L).

-Serum osmolality > 320 mOsm/kg.

-blood pH > 7.3.

-Serum bicarbonate greater than 15 mEq/L.

-Normal anion gap (less than 14 mEq/L).

 Core subject
HYPEROSMOLAR HYPERGLYCEMIC
STATE(HHS)
 Core subject
HYPEROSMOLAR HYPERGLYCEMIC
STATE(HHS)
• Onset may be insidious over a period of days or weeks, with
weakness, polyuria, and polydipsia.
• Mainly in T2DM
• MANAGEMENT:
-if hypovolemia, start with 0.9% saline. In All other cases start with
0.45% saline.
- insulin infusion rate at 0.05 unit/kg/h
- LMWH to prevent DVT.
Core subject
Core subject
HYPOGLYCEMIA
 Core subject
HYPOGLYCEMIA

Serum glucose level < 55 mg/100ml

 brain damage develops when the brain is
deprived of needed glucose after a dramatic
drop in blood sugar
 i nsulin reaction, insulin shock, “the lows”
Mismatch between insulin dose,
carbohydrate availability and exercise
 HYPOGYLCEMIA Core subject

 Causes:
 Excess or overdose of insulin or OHA (oral hypoglycemic
agents)
 Skip meal or omitting a meal
 Overexertion/ stress
 Under-eating
 Eating late
 Unplanned exercise
 Core subject
HYPOGLYCEMIA:
SIGNS & SYMPTOMS

Mild
 Diaphoresis
 Pallor
 Paresthesia ANS/Adrenal Medulla
 Palpitations
 Tremors
 Anxiety

Note: Clients taking medications, such as beta-adrenergic

blockers may not experience manifestations associated with
autonomic nervous system
 Core subject
HYPOGLYCEMIA:
SIGNS & SYMPTOMS

Moderate: Severe
 Confusion/  Seizures
disorientation  Loss of Consciousness
 Behavioral Changes  Shallow respirations
 Severe hypoglycemia
 cold clammy can result in death
extremities,
 yawning,
 tremors,
 blurred vision
 Core subject
HYPOGLYCEMIA: DIAGNOSIS

 Signs & Symptoms

 FSBG or FSBS
 Core subject
MANAGEMENT: MILD

 Simple Sugars p.o (15 gm of rapid-acting

sugar)
 8 oz fruit juice
 8 oz of skim milk
 3 glucose tablets
 3-4oz regular soft drink
 3-4 pieces hard candy ( life savers)
 1 tbsp sugar
 5 ml pure honey
 Core subject

RULES TO REMEMBER

Recheck FSBS/CBG q 15 min until WNL

Avoid high fat  slows absorption of
glucose
Instruct: carry fast sugar
If meal is >1 hr away, follow with a
protein and complex carbohydrate
NPO if “unconscious” or confused
 Core subject

15/15 rule: wait 15 minutes and monitor

blood glucose; if still low (BG<80),
should eat another 15 gm of sugar
Continue until blood glucose level has
returned to normal
 should contact medical care
provider if hypoglycemia occurs more
than 2 or 3 times per week
 Core subject
HYPOGLYCEMIA TREATMENT
UNCONSCIOUS

Glucagon 1 mg Subq, IM, IV; follow with

oral or intravenous carbohydrate
Action: (hormone)  raises BS levels
Onset:10 minutes
Duration 25 minutes
S/E: N/V
Position: side lying
 HYPOGLYCEMIA TREATMENT Core subject

UNCONSCIOUS

Or give 25mL of D50

as IV push
followed by infusion
of 5% dextrose in
water
 Core subject
HYPOGLYCEMIA
GERONTOLOGICAL CONSIDERATION

Cognitive deficits 
 not recognize S&S
Decreased renal function 
 oral hypoglycemic meds stay in body longer
More likely to _________a meal
 Skip
Vision problems 
 inaccurate insulin draws
 Core subject
HYPOGLYCEMIA
NURSING MEASURES

Follow protocol
Teach
Carry simple sugar at all times
S&S or hypoglycemia
How to prevent Hypoglycemia
Check FSBS if you suspect  NOW!
 Core subject
HYPOGLYCEMIA
NURSING MEASURES

Encourage to wear ID bracelet

Teach family that belligerence is sign of
hypoglycemia
 Core subject

PREVENTION OF COMPLICATIONS

1. Managing diabetes

2. Lowering risk factors for conditions
3. Routine screening for complications
4. Implementing early treatment
 Researchers and References Vertical
integration

• https://www.uptodate.com/contents/table-of-
contents/endocrinology-and-diabetes/diabetes-mellitus
• https://www.diabetes.org.uk/guide-to-diabetes/complications
• https://www.idf.org/aboutdiabetes/complications.html

• Harrison’s Principles of Internal Medicine

• Davidson’s Principles and Practice of Medicine
• Current Medical Diagnosis and Treatment 2022
• The Oxford Textbook of Medicine