Complication of diabetes: Acute Complication Chronic Complication • Hyperosmolar Hyperglycemic Non-Ketotic syndrome • Diabetic Ketoacidosis • Hypoglycemia • Micro vascular Complication Macro vascular Complication • Diabetic Nephropathy Coronary Artery Disease • Diabetic Neuropathy Peripheral Vascular Disease Diabetic Retinopathy Cerebro Vascular Disease
1.) Hyperosmolar hyperglycemic non- Ketotic syndrome (HHNK): • It is defined as an extremely high blood glucose level, absence of or only small amount of ketones and profound dehydration. • Glucose levels generally range from greater than 600 to 2000mg/dl. • Patient who have HHNK syndrome have sufficient insulin to prevent lipolysis and ketosis. • This condition occur rarely in older patient with type 2 diabetes.
Sign and symptoms: • Blood sugar level over 600mg/dl. • Dry, parched mouth. • Extreme thirst. • Warm, dry skin that does not sweat. • High fever. • Sleeping or confusion Hallucinations. • Weakness or paralysis on one side of the body. • loss of vision. • profound dehydration (10%-15% loss of body water) • Treatment: • Intravenous fluid. • Small amount of insulin is given to correct hyperglycemia.
2.) Hyperglycemia/diabetic ketoacidosis (DKA) • Diabetic ketoacidosis (DKA), a life-threatening complication characterized by severe disturbances in carbohydrate, protein, and fat metabolism. • DKA is always the result of inadequate insulin for glucose use. • As a result, the body depends on fat for Energy and ketones are formed. • Acidosis results from increased production and decreased use of acetoaceticacid and 3-B-hydroxybutyric acid from fatty acids. • These ketones spill into the urine; hence the reliance on testing for ketones.
DKA is characterized by elevated blood glucose levels (>250 mg/dl but generally <600 mgldl) and the presence of ketones in the blood and urine. • Acute illnesses such as flu, colds, vomiting, and diarrhea, if not managed appropriately, can lead to the development of DKA. • If DKA left untreated, It can lead to coma and death.
Symptoms include: • Headache • Anorexia • Nausea • Dehydration • Polydipsia • The fruity odor of ketones • Fatigue • Low blood pressure • Constipation • Muscle cramps • Altered vision • Treatment: • Increase regular insulin dose by at least 20%. • Fluid and electrolyte replacement. • Medical monitoring • .
3.) Hypoglycemia: • This is a condition of low blood glucose levels as a result of- overdose of insulin, failure to eat food after a dose of insulin, loss of food through vomiting or diarrhea or exercise without modifying the insulin dose. • Blood glucose level fall to as low as 50mg/100ml. • Hypoglycemia is a common side effect of insulin therapy.
Causes of Hypoglycemia • Deliberate errors in insulin doses • Excessive insulin or oral secretagogue medications • Improper timing of insulin in relation to food intake • Omitted or inadequate meals or snacks • Delayed meals or snacks • Unplanned or increased physical activities or exercise • Alcohol intake without food.
Treatment of hypoglycemia: • If the blood glucose level falls,15 g of carbohydrate should be given. • If the patient is so stuporous that he can’t swallow, given an intravenous injection of 25 g of glucose. • As patient is able to swallow, he should be given 30 g of sugar by mouth. • The patient must be educated that unpunctual meals and unaccustomed exercise may precipitate hypoglycemia and they must always carry some tablets of glucose or some sugar for use in an emergency. • Patients need to be reminded of the need to treat hypoglycemia , even in the absence of symptoms.
HYPERGLYCEMIA AFTER HYPOGLYCEMIA • Hypoglycemia followed by “ rebound” hyperglycemia is called the somogyi effect. • This phenomenon originates during hypoglycemia with the secretion of counter regulatory hormones and is usually caused by excessive exogenous insulin doses. • Hepatic glucose production is stimulated thus raising blood glucose levels. • If rebound hyperglycemia goes unrecognized and insulin doses are increased, a cycle of over insulinization may result.
Chronic or long term complication: • 1.) Macrovasculardiseases involve diseases of large blood vessel. In this blood vessel walls become thicken, and closed by plaque then blood flow is reduced or blocked. Macrovascular diseases including: coronary heart disease (CHD), peripheral vascular disease (PVD), and cerebro vascular disease (CVD).
i.) Coronary artery disease: • In this condition blood vessel of the heart become narrowed or blocked by plaque, and the blood supply to heart is reduced or cut off, resulting in a heart attack. • Symptoms: • Dyspnea (Difficulty in breathing). • Fatigue • Chest pain • Weakness • Paroxysmal nocturnal (Shortness of breath).
ii.) Cerebral vascular disease: • It is caused by narrowing, blocking, or hardening of brain blood vessel or by high blood pressure. It affects the blood flow to the brain, leading to stroke. • Stroke: A stroke result when blood supply to the brain is suddenly cut off, which can occur when a blood vessel in the brain or neck is blocked or bursts. • Brain cells are then deprived of oxygen and die.
Symptoms of cerebro vascular disease: • Dysarthria (Disorder of speech) • Unilateral weakness • Vision difficulty in one or both eyes • Severe headaches
iii.) Peripheral vascular disease: • In this condition, blood vessel in the legs are narrowed or blocked by plaque, blood flow is decreased to the legs and feet. • Poor circulation in the legs and feet raises the risk of amputation. Symptoms: • Foot ulcer • Pain in buttocks, thighs and calf.
Causes of macro vascular disease: • High triglyceride level • High LDL Cholesterol level • Lower HDL cholesterol levels • High blood pressure • Smoking • Poor blood glucose control • Obesity • Little exercise
Management of Macro vascular disease: • Decrease blood pressure to a desirable value 130/80mm. • Reducing LDL cholesterol concentrations to less than 100mg/dl. • Decrease daily fat intake • Control blood glucose level. • Diet and exercise are important for obesity and hypertension.
Hypertension: • Hypertension is a common comorbidity of diabetes, about73% of adults with diabetes having blood pressure of 130/80 mm Hg or higher. Treatment of hypertension: • Blood pressure should be measured at every routine visit. • Medical nutrition therapy. • Drug therapy.
2.) Micro vascular disease: • Micro-vascular diseases associated with diabetes involve the small blood vessels. It include: • Diabetic Retinopathy • Diabetic Nephropathy • Diabetic Neuropathy
1.) Diabetic retinopathy: • Diabetic retinopathy (DR) can be defined as damage to micro vascular system in the retina due to prolonged hyperglycaemia. • After 20 years of diabetes, nearly all patients with type 1 diabetes and more than 60% of patients with type 2 diabetes have some degree of retinopathy.
There are two stages of diabetic retinopathy: • Non proliferative Diabetic Retinopathy • Proliferative Diabetic Retinopathy.
1.) Non proliferative Diabetic Retinopathy: • The early stage is non proliferative diabetic retinopathy (NPDR). • It has three stages: • Mild Non proliferative Retinopathy: At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels. • Moderate Non proliferative Retinopathy: As the disease progresses, some blood vessels that nourish the retina are blocked.
Severe Non proliferative Retinopathy: Many more blood vessels are blocked, it results more areas of the Retina being deprived of nourishment and oxygen. • A lack of sufficient oxygen supply to the Retina results in a condition called “Retinal Ischemia”. • These areas of the retina send signals to the body to grow new blood vessels for nourishment.
2.) Proliferative Diabetic Retinopathy (PDR): • It is the most advanced and most vision-threatening stage of diabetic retinopathy. • At this advanced stage, the signals sent by the retina for nourishment cause the growth of new blood vessels. • The new blood vessels grow along the retina and along the surface of the clear, vitreous gel that fills inside of the eye. • The new vessels are fragile and prone to bleeding, resulting in vitreous hemorrhage and retinal detachment. • These changes interfere with vision and may ultimately lead to blindness.
. 3.) Diabetic macular edema • Diabetic macular edema, involves thickening of the central (macular) portion of the retina, and glaucoma, in which fibrous scar tissue increases intraocular pressure. • Macular edema may cause reduced or distorted vision. • Diabetic macular edema can be present at any stage of the disease, but is more common in patients with proliferative diabetic retinopathy.
Symptoms : • Blurry or double vision. • Flashing lights or blank spots. • Dark or floating spots. • Pain or pressure in one or both eyes. • Difficulty in seeing the things out of the corner of eyes. • Risk factor: • Poor blood sugar control. • High blood pressure • Raised level of fat in blood. • Longer you have had diabetic.
Management of Diabetic Retinopathy: • Keep your blood glucose and blood pressure as close to normal as you can. • Examine your eye once a year. Treatment: Laser treatment: Laser treatment is used to stop the leakage of blood and fluid into the retina. A laser beam of light can be used to create small burns in areas of the retina with abnormal blood vessels to try to seal the leaks.
Vitrectomy: • when you have a lot of blood in the centre of eye need vitrectomy to restore your sight. • A tiny incision is made in eyes, then a small instrument is used to remove viterous gel that is clouded with blood . • The viterous gel is replaced with a salt solution.
2.) Diabetic Nephropathy: • Functional changes occur in the nephrons of the kidney. • The basement membrane of the glomeruli thickens which may lead to diabetic glomerulosclerosis. • Which of two types : Diffuse and Nodular • Diffuse is more common with generalized thickening of capillary walls. • while in case of the nodular, rounded masses of acellular, hyaline material are superimposed on the diffuse lesion of the glomeruli. These are called kimmelstiel - wilson nodules. • These changes lead to proteinuria with increasing renal failure and uraemia, if diabetes is uncontrolled. • About 20 to 40% of patients with diabetes develop evidence of nephropathy.
Clinical evidence of nephropathy is the appearance of low but abnormal urine albumin levels (30 to 299 mg/24 hr), referred to as microalbuminuria. • Microalbuminuria is rare during the First five year after onset of diabetes. • Microalbuminuria is also a marker of increased cardiovascular disease risk. • When diabetic nephropathy has continued for some time, the condition will develop into something called End-Stage Renal Disease (ESRD). At this point, the kidney will have completely stopped functioning, and a kidney transplant or dialysis will become necessary.
Symptoms: • Weight gain • Elevated blood urea nitrogen (BUN) and creatinine levels • Uncontrolled hypertension • Uremia due to accumulation of metabolic wastes • Ankle and leg swelling(Pedal edema) • Reduced urination (<400ml/day-oliguria) • Anorexia and weakness • Nausea and vomiting • Itching • Breathlessness • Palpitation
Management: • Exercise daily and loss weight to maintain ideal body weight. • Avoid tobacco and alcohol. • Avoid nephrotoxicdrugs like NSAIDS • Glycemiccontrol of HbA1c<7% • Blood pressure control of <130/80mm hg • Appropriate diet • Test regularly for microalbuminuria
Diabetic Neuropathy: • Damage to the nerve is called neuropathy. Neuropathy as a result of diabetes is called diabetic neuropathy. • Chronic high levels of blood glucose are associated with nerve damage and affect 60 to 70% of patients with both type I and type 2 diabetes. • Damage nerves cannot pass the signals to and from the brain properly. As a result, either have loss of sensation or pain in the affected parts.
Symptoms of Neuropathy: • Numbness, tingling or pain in toes, feet, legs, arms and fingers • Wasting of muscle of feet or hands • Nausea or vomiting • Diarrhea or constipation • Weakness • Dizziness or fainting
Type of Diabetic Neuropathy: • Chronic Peripheral Neuropathy • Autonomic Neuropathy • Proximal Neuropathy • Focal Neuropathy
I.) Chronic Peripheral neuropathy: • It is also called distal symmetric neuropathy or sensorymotor neuropathy. • It affects the nerves of Toes, feet , legs, hands and arms. • Peripheral neuropathy may cause muscle weakness and foot deformities. • This form is common in elderly diabetics with long-standing disease, but rare in diabetics under 20 year of age.
Symptoms: • Numbness • Tingling or burning sensation • Loss of balance and coordination. • Extreme sensitivity to touch • Sharp pain or cramps • Loss of vibration sense at the ankle or knee.
2.) Autonomic Neuropathy: • Autonomic neuropathy affects nerve that control heart, regulate Blood pressure and control blood glucose level. • It also affects-Bladder,Intestine,Sexorgan and Lungs.
Autonomic nervous system cause: • Diarrhea, • Impotence and postural hypotension • Disturbances of sweating
3.) Proximal Neuropathy: • It is also called diabetic amyotrophy. • In this pain is occur in hips, buttocks, thighs and legs , usually on one side of body. • It can lead to weakness in legs. • This type of neuropathy is more common in those with type 2 diabetes and in older adults with diabetes.
Focal Neuropathy: • Focal neuropathy appear suddenly and it affects specific nerves most often in the head or legs. Focal neuropathy may cause: • Double vision • Paralysis on one side of face called bell’s palsy. • Severe pain in the lower back or pelvic. • Stomach, chest or side pain • Pain inside the foot
Management of Neuropathy: • Bring blood glucose level with in the normal range • Adequate diet • Foot care • Medication