Acute And Chronic Complications Of Diabetes

Front 1

What are the acute metabolic complications of diabetes mellitus?

Back 1

DIabetic ketoacidosis
Hyperglycemic, hyperosmolar state

Front 2

What is the definition of diabetic ketoacidosis?

Back 2

A life-threatening state that results from a relative or absolute deficiency of insulin

Front 3

What kinds of diabetics are more likely to develop ketoacidosis?

Back 3

Type 1

Front 4

What are the problems that result from too little insulin? Too much insulin?

Back 4

Too little: DKA
Too much: hypoglycemic

Front 5

What, other than too little insulin, can push a type 1 diabetic into DKA?

Back 5

Illness
Stress

Front 6

What hormones are found in high levels in DKA?

Back 6

Stress hormones:
-Epi
-Norepi
-GH
-Cortisol

Front 7

What are the precipitating factors for DKA?

Back 7

Insufficient or no insulin
Physical stress
Surgery, infections, heart attacks, etc.

Front 8

How does DKA develop in people who are insulin deficient?

Back 8

Decreased activity of LPL inside cell (less incorporation of fat) and increased activity of HSL

As a result, more FFAs are present in the circulation,

Also, stress hormones cause the release of FFAs.

Front 9

Where in the body are ketone bodies made?

Back 9

LIVER.

Front 10

What are the ketones present in diabetic ketoacidosis?

Back 10

Acetoacetate
Beta-hydroxybutyrate

Front 11

What is the action of ketone bodies in diabetic ketoacidosis?

Back 11

Weak acids; donate protons

Front 12

What are the symptoms of hyperglycemia?

Back 12

Polyuria, polydipsia
Severe volume depletion
Electrolyte depletion

Endpoint: renal hypoperfusion, prerenal azotemia, hypotension, shock

Front 13

What are the symptoms of ketones in the blood?

Back 13

Acidosis
Compensatory respiratory alkalosis
Hypotension
Shock

Front 14

What's the clinical course of diabetic ketoacidosis?

Back 14

1. Precipitating event
2. Polyuria, polydipsia, dehydration
3. Anorexia, nausea, vomiting, abdominal pain
4. Kussmal respirations, "juicy fruit" breath
5. Altered complications
6. CV collapse
7. Coma, death

Front 15

What's the cause of impairment of CNS function in DKA?

Back 15

Hypertonicity
Hypotension
Acidosis

Front 16

What is the diagnositc triad of DKA?

Back 16

Increased blood glucose
"Gap" metabolic acidosis
Increased serum ketones

Front 17

What's the formula for anion gap?

Back 17

Front 18

What's the cause of an increase in anion gap?

Back 18

Increases in organic acids (ketone bodies, essentially) causes a decrease in HCO3, increasing the gap

Front 19

If someone has a fever and is diabetic, what should you think?

Back 19

DON'T ALWAYS ASSUME DKA!!!!

Think infection until proven otherwise

Front 20

What's the treatment for DKA?

Back 20

1. IV insulin
2. IV fluids: RAPID
3. Replace electrolytes (Na, K, Mg, PO4)
4. Carbohydrate replacement once serum glucose is below 250 mg/dL
5. Diagnose and treat the PRECIPITATING EVENT!

Front 21

What should you not administer during DKA?

Back 21

Bicarb.

Front 22

What's the purpose of administering insulin in DKA?

Back 22

1. Shut down lipolysis
2. Lower blood sugar.

Front 23

What shouldn't you do while treating DKA?

Back 23

Shut off the insulin too early.

This is the MOST COMMON MISTAKE THAT PEOPLE MAKE WHILE TREATING PEOPLE WITH DKA!!!!!!!!

Front 24

What happens to potassium stores in DKA?

Back 24

They're overall decreased, despite elevation in the serum.

During acidosis, you get a shift of H into cells, with K coming out.
Increased serum load of K means peeing out K

Front 25

What's the effect of giving insulin on serum K?

Back 25

Driving K back into cells

THIS IS BAD.

Front 26

What should you do as soon as you see someone peeing with DKA?

Back 26

Give them K!

If the kidneys don't work, don't give them K. You'll kill them due to hyperkalemia!

Front 27

What should you follow when treating DKA? Why?

Back 27

Anion gap, not ketone levels.

Acetone is produced during the regeneration of bicarb. Ketone levels are going to actually INCREASE during therapy.

Front 28

What happens in a hyperglycemic hyperosmolar state?

Back 28

Life-threatening metabolic disorder of extreme hyperglycemia without ketosis

Front 29

Who typically gets into a hyperglycemic hyperosmolar state?

Back 29

Elderly with type 2 diabetes

30% haven't been diagnosed!

Front 30

What are common precipitating events causing a hyperglycemic hyperosmolar state?

Back 30

MI
Stroke
Sepsis

Front 31

What's the prognosis from a hyperglycemic hyperosmolar state?

Back 31

>40% mortality

Front 32

What is the cycle that happens in a hyperglycemic hyperosmolar state?

Back 32

Front 33

What are complications following volume depletion and hemoconcentration in a hyperglycemic hyperosmolar state?

Back 33

Hyperviscosity --> increased thrombosis risk

Disturbed mentation and obtundation

Neurologic signs

Front 34

What are some neurologic signs secondary to volume depletion in a hyperglycemic hyperosmolar state?

Back 34

Focal signs: sensory/motor deficits or focal seizures

Motor abnormalities

Front 35

What are the levels of hyperglycemia in hyperglycemic hyperosmolar state?

Back 35

1700-1800!

Super dooper high!

Front 36

Why is it that people go into a hyperglycemic hyperosmolar state instead of DKA?

Back 36

They still have enough residual insulin to prevent lipolysis

However, they don't have enough insulin to control blood sugars

Front 37

What's the treatment for a hyperglycemic hyperosmolar state?

Back 37

Volume correction with normal saline
Replacement of electrolytes
IV insulin
Diagnosis and tx of underlying cause

Front 38

What are the chronic complications of diabetes?

Back 38

Retina
Kidneys
Nerves

Heart, brain, large vessels

Front 39

What organs are impacted by microvascular complications of diabetes?

Back 39

Retina
Kidneys
Nerves

Front 40

What organs are impacted by macrovascular complications of diabetes?

Back 40

Heart
Brain
Large vessels

Front 41

What is the progression of diabetic retinopathy?

Back 41

Front 42

What are hard exudates in the retina?

Back 42

Areas of protein leakage with iscemia

Front 43

What are the stages of diabetic retinopathy?

Back 43

1. Non-proliferative
2. Proliferative

Front 44

What happens when there is chronic disease in the retina?

Back 44

New vessel formation due to the edema.

These vessels can scar.

Ultimately you get retinal detachment, which leads to blindness

Front 45

What's the leading cause of new adult blindness in the United States?

Back 45

Diabetic retinopathy

Front 46

What changes occur to the kidneys in diabetic nephropathy?

Back 46

Basement membrane thickening and mesangial cell proliferation

Dropout of adipocytes

Front 47

How can you go about looking for early stages of diabetic nephropathy?

Back 47

Albumin screening

Microalbuminuria is a sign of early nephropathic change

Front 48

What's the leading cause of renal failure leading to dialysis in the US?

Back 48

DIBITUS!!!

Front 49

Where are the first places that diabetic neuropathy shows up?

Back 49

The extremities: stocking-glove distribution

Front 50

What are the changes that happen with diabetic neuropathy?

Back 50

Decreased vibration, temperature, proprioception

Front 51

What are the early signs of diabetic neuropathy?

Back 51

Parasthesias: burning, pins, etc.

Front 52

What are complications that can occur to feet in diabetic neuropathy?

Back 52

Foot ulcers
Charcot feet: people walk abnormally, causing bone remodeling that disfigures the feet.

Front 53

What are some other (other than distal, that is) neuropathies that happen in diabetes?

Back 53

Gastroparesis-->constipation/diarrhea
Erectile dysfunction
Urinary retention
Chronic edema
Postural hypotension
Cardiac arrhythmias
Abnormal sweating
Increased callus formation

Front 54

What's the leading cause of non-traumatic lower extremity amputation in the US?

Back 54

Diabetes

Front 55

What are some macrovascular complications of diabetes?

Back 55

Gangrene
Coronary heart disease
Stroke

Front 56

What are the properties of MIs that happen in diabetes?

Back 56

THEY OFTEN DON'T HAVE CHEST PAIN!!!

ALWAYS JUST GET AN EKG!!!!!!!!!!

Front 57

What are complications for the mother during pregnancy in diabetes?

Back 57

Insulin requirements increase
Retinopathy, nephropathy worsen

Front 58

What are the complications for the baby in the pregnancy of a person with diabetes?

Back 58

Infant mortality is increased
More congenital malformations
Respiratory distress syndrome is more common

Big babies - they're GIANT!

Front 59

What is the impact of hyperglycemia on wound healing?

Back 59

Decreased:
-WBC motility
-WBC opsinization of bacteria
-Fibroblast collagen issues

Front 60

What are infectious complications of diabetes?

Back 60

Complications from influenza are more common in diabetic individuals

Tb and pneumococcal pneumonia are common

Yeast infections in women