Dr: Barjas al-mutairi Family physician

ACUTE COMPLICATION OF DM

Acute complication of DM

Hypoglycemic crisis

Hyperglycemic crisis

hypoglycemia
It is an important problem in type 1 diabetes,

especially in patients receiving intensive therapy in whom the risk of severe hypoglycemia is increased more than threefold Less commonly ,hypoglycemia may also affect patient with type 2 diabetes who take a sulfonylurea or meglitined or who use insulin

 ADA published criteria for definition and

clinical classification of hypoglycemia in patient with DM definition: In patient with DM ,hypoglycemia is defined as all episodes of an bnormally low plasm glucose concentration (with or without symptoms) that expose the individual to harm

Classification of hypoglycemia in diabetes

Severe hypoglycemia:

- an event requiring the assistance of anther persone to actively adminster carbohydrate ,glucagon or resuscitative action Documented symptomatic hypoglcemia: - an event during which typical symptoms of hypoglacemia are accompanied by meaured plasma glucose concentration 3.9 mmol/l

 Asymptomatic hypoglacemia: An event not accompanied by typical

symptoms of hypoglacemia but with a measured plasma concentration of 3.9 mmol/l Probable symptomatic hypoglacemia: an event during which typical symptoms of hypoglycemia are not accompanied by glucose determination

Relative hypoglycemia: An event during which the person with diabetes report typical symptoms of hypoglycemia and interprets those as indicative of hypoglycemia, but with measured plasma glucose concentration >3.9 mmol/l This category reflects the fact that patients with chronically poor glycemic control can experience symptoms of HG at plasma glucose levels>3.9mmol/l

Clinical manifestation
Any patient with acute change in mental

status or coma should undergo rapid assessment of B.S as apossible cause All finding of hypoglycemia symptoms are nonspecific including the following: A- the neurogenic symptoms : sweatingweakness-tachycardia-palpitation-tremornervousness-hunger-paraethesia

Clinical manifestation
B-neuroglycopenic symptoms: Cognitive impairment Behavioral changes Psychomotor abnormalities Seizure Visual distarbance coma

treatment
A- if the patient is conscious and able to drink

and swallow safety: -administer a rapid absorbed carbohydrate e.g 3-4 glucose tablets Tube of gel with 15 g of glucose Fruit jucie Teaspoon of hony or table suger

treatment
B- if the pateint has altered mental status,or unable to swallow, does not responed to oral glucose administration within 15 minutes give an iv bolus of 12.5-25 g(25-50ml of 50% dextrose) -then measure a blood suger 10-15 minutes after iv bolus -Monitor every 30-60 minutes therafter untile stable -Readminister 12.5-25 g of glucose as needed to maintain the B.S above 80 mg/dl

 C- if glucose cannot be given by parenteral or

oral routes ,give glucagon 1 mg im or sc: - the response may be transient - Should be followed by careful glucose monitore and oral or iv glucose adminstration Once the patient is able to ingest carbohydrate safely, providing a mixed meal

Advice to the patients

Check blood sugar before driving and every 2

hr during long journey Carry glucose everywhere and sandwiches on long journeys If hypoglycemia occurs ,stop hazardous activities and take evasive action Wait until fully recovered before resuming activities

admination
Patient who: -ingestion of long acting hypoglycemic agent Recurrent hypoglycemia during observation Those unable to eat

hyperglycemia
Daibetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS, also called nonketotic

hyperglycemia) are two of the most serious acute complication of diabetes.

DKA and HHS are responsible for about 100,000 hospital admissions per year.

. The mortality rate for DKA is less than 5 percent, while the rate for HHS is about 15 percent

Hyperglycemia crises
There is significant overlap between DKA and

HHS occurs in more than one third of patients

DKA is common in a patients with type 1. HHS is common in a patient with type2

Hyperglycemia
DKA and HHS differ clinically according to the

presence of ketoacidosis and the degree of hyperglycemia .

Table 1 show the clincal red flags

suggesting a hyperglycemia crisis:

symptoms signs
rapid onset<24h Nausea& vomiting Abdominal pain malaise Mild dehydration Rapid, deep breathing Fruity smelling breath B.S=13.4 mmol/l UA=postive

diagnosis
DKA

Gradual onset(daysweek)Nausea& vomiting-Abdominal pain-Headacheweight losspolydipsia-Thirstpolyuria-lethargydizziness

sever dehydration Mental status changes Coma Focal neurological signs Seizures B.S=>33.3 UA=small or negative

HHS

treatment
Both DKA and HHS needs to be admit

immediately to hospital

IV rehydration (500ml/hr) O2 therapy 3l/min

prevention
When you are sick: Check blood sugar every three to four hours

during illness. If blood sugar gets high (usually over 250 mg/dl) check more often and check for ketones in your urine. During illness, make sure to drink plenty of sugar-free, caffeine-free liquids. Don't stop taking your insulin when you are sick, even if you are not eating.

Preventing DKA that is not associated with illness:

- If you use an insulin pump, check it often to make sure that it is working properly and administering insulin. - Check blood sugar often throughout the day, usually four times a day. - Don't skip insulin doses or if you are Type 2 make sure to take your oral medications as prescribed