management of complications of diabetes

1. MANAGEMENT OF DIABETIC
COMPLICATIONS
Bir Bdr. Bal Tamang
Roll no:13

2. DIABETIC KETOACIDOSIS(DKA)
- Most commonly seen in type 1 DM
- It is a medical emergency
The principles of management includes;
1. Correction of dehydration
2. Control of hyperglycemia
3. Correction of electrolyte imbalance and acidosis
4. Supportive measures.
5. Identification of underlying causes :
infections(UTI, pneumonia, pancreatitis) ,MI &
drugs like steroids

3. When the pt. comes to ER
Initial evaluation:
- Check level of conciousness
- Maintain airway, breathing and circulation
- If vomiting and altered mental status, insert
NG tube to prevent aspiration
- ICU admision for frequent monitoring

4. Assess the patient :
• History and physical examination
• Lab investigation:
 Blood sugar
 ABG to see electrolyte imbalance
 CBC with differential count to rule out
infection
 ECG- to rule out MI
 RFT

5. Treatment
• Start with I.V. 0.9 % NS 1L / hr @ 15-20
ml/kg/hr
• Confirm the diagnosis:
- Blood glucose : > 250 mg/dl
- Arterial pH : < 7.30
- S. Bicarbonate : <15 mEq/L
- Ketonuria and ketonemia

6. Fluid Resuscitation
a) Average fluid deficit=3-6 litres.
 2-3 L of 0.9 % isotonic saline over 1-3 hours @
10-15 ml/kg/hr followed by hypotonic
saline(0.45% NaCl) @150-300 ml/hr( only
when hemodynamically stable & urine output
is adequate)
 Monitor BP, Pulse, urine output and mental
status
c) When Blood glucose comes to < 200 mg/dl ,
isotonic solution is replaced with 5-10%
dextrose with ½ NS(0.45%) @100-200 ml/hr

7. INSULIN THERAPY :
 Insulin should be started about an hour after the
fluid replacement to check the blood K+ level
 If serum K+ is <3.3 mmol/L, do not administer the
insulin until it is corrected to >3.3
 Initial bolus dose of Regular insulin 0.1U/kg i.v.
followed by 0.1 U/kg/hour i.v. infusion as
maintenance dose
 Decline in blood glucose about 50-100 mg/ hour
is the adequate response
- Continue insulin until ketonuria & ketonemia are
absent and anion gap is in normal level

8. Potassium replacement
• If S. potassium= > 5.5 mEq/L - no supplement is
required
• If 3.5- 5.5 mEq/L 10 mEq/h of KCl
• If < 3.5mEq/L 20 mEq/h of KCl
Monitor S. potassium levels hourly and the infusion
must be stopped if the S. pot. Level > 5.5 mEq/L

9. BICARBONATE THERAPY
• pH ≥ 7 no bicarbonate is required
• pH< 7 and HCO3 < 5 mEq/L 45 mEq in
500 ml 0.45% saline over 1 hr until pH ≥ 7

10. Hyperglycemic Hyperosmolar state(HHS)
• Mainly seen in elderly pt with T2DM
• Characterized by profound hyperglycemia and
dehydration
• Most often due to precipitating factors like
infection ,MI , drug therapy- corticosteroids

11. Management of HHS
• Correction of hypovolemia
• Identify and treating underlying cause
• Correction of electrolyte abnormalities
• Gradual correction of hyperglycemia and
osmolarity
• Patients are prone to develop thrombosis-
prophylactic heparin -LMWH
• Frequent monitoring
Treatment goals:

12. ASSESSMENT
• Absent ketone bodies
• Severe hyperglycemia: >600mg/dl
• Osmolality : > 320mosmol/kg
• Check the underlying cause: infections ,MI etc.

13. Fluid resuscitation
• Give normal saline
1 L first 2 hrs
1L next 2-4 hrs
1 L over 4-6 hrs
• Avoid rapid rehydration because of cerebral
edema
• Avoid overhydration & too rapid fall of BSL
(hypotention)

14. Hypoglycemia treatment

15. MILD HYPOGLYCEMIA
• Oral carbohydrates (glucose tablet )at least
15gm with 2 cups of fruit juice
• If the patient is unable to take orally, I.V
Dextrose can be given

16. MODERATE TO SEVERE HYPOGLYCEMIA
• 50 ml of 50 % Dextrose IV bolus after blood
draw followed by 10 % Dextrose
• Glucagon 1 mg IM or SC can be given
• Patient is urged to eat as soon as possible

17. Prevention of hypoglycemia
• Patient education
• Knowing signs and symptoms of
hypoglycemia
• Take meals on regular schedule
• Carry a source of carbohydrate
• Self monitoring of blood glucose
• Take regular insulin at least 30 min before
eating

18. Cardiovascular complications includes
HTN; Atherosclerosis, MI etc.
MI may precipitate the DKA ,so strict
control of BGL is needed using insulin.
Hypoglycemia should be avoided since
it may lead to extension of infarct.

19. MANAGEMENT OF EYE DISEASES
Diabetic Retinopathy:
Non proliferative-metabolic control of BGL
Medical t/t: intravitreal anti-VEGF drugs eg Ranibizumab
or intravitreal triamcinolone
Proliferative –Laser photocoagulation
therapy or surgical t/t PPV
Cataract –cataract surgery

20. Management of Nephropathy
• Good glycemic control for hyperglycemia
• Aggressive treatment of BP(<130/80 mmHg)
• ACE Inhibitor – for T1DM
• ARB – for T2DM
• Statins for Hypercholesterolemia
• Renal transplantation for end stage renal
failure

21. Management of Diabetic Neuropathy
-For pain and paraesthesia from peripheral
somatic neuropathies:
 Opiates – Tramadol
 Intensive insulin therapy
 TCA - Amitryptyline
-For gastroparesis- dopamine antagonist-
Domperidone
- Erectile dysfunction- phosphodiesterase-5
inhibitor - Oral Sildenafil
- For atonic bladder- intermittant self-
catheterization

22. Diabetic Foot Ulcer(DFU)
Prevention of diabetic foot ulcer:
Diabetic foot care:
Advice to the patient:
• Inspect and wash the foot everyday
• Cut nails of foot regularly
• Avoid walking barefoot
• Wear suitable and well-fitting shoes

23. DFU management:
• Debridement of dead tissues
• Treatment with antibiotics if required as infection can accelerate tissue
necrosis and lead to gangrene
• Pressure relief using dressings
• In case of severe secondary infection or gangrene- amputation may be
required

24. “The most serious complication of
Diabetes is Diabetes itself”
“The best of all complication management strategies
must not be other than Good Glycemic Control on our
day to day life”