This document provides information on the acute complications of diabetes mellitus, including diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state, and hypoglycemia. It describes the presentation, pathophysiology, clinical manifestations, diagnostic evaluation, differential diagnosis, treatment and goals of treatment, and prevention of these complications. DKA is characterized by high blood glucose, low pH, and ketones in the blood or urine. Treatment involves fluid resuscitation, insulin administration, electrolyte replacement, and identifying and treating any precipitating factors. Hyperosmolar hyperglycemic state typically occurs in elderly patients with type 2 diabetes and lacks significant ketosis or acidosis. Hypoglycemia can be precip

1. Diabetes Mellitus
Acute Complications
PRESENTATION BY DR. ANAND SINGH BHADORIYA
MBBS (GRMC, GWALIOR)

2. Introduction
ACUTE COMPLICATIONS
• Diabetic Ketoacidosis
• Hyperosmolar Hyperglycemic state
• Hypoglycemia

3. DKA
• Any time during course of disease
• Significant morbidity
• Most common cause of mortality in children
and adolescents
• Overall mortality - 5%
• Mainly in type-1 DM

4. Definition
• Plasma glucose > 250 mg%
• pH < 7.3
• Serum Bicarbonate < 18 meq/L
• Urine ketone >1:4 or serum ketone 1: 2
dilution

5. Actions of Insulin

6. Pathophysiology

7. Precipitating Factors
• Type 1 DM first presentation
• Inter-current illness
• Omitting / under-dosing Insulin in Type 1 DM
>children, undiagnosed cases
Adolescents – omission
Puberty - Increased requirement
Infrequent sugar monitoring
Improper testing / Administration technique

8. Clinical Manifestations
Symptoms
• Nausea / vomiting
• Thirst / Polyuria
• Abdominal pain
• Altered mental status
• Shortness of breath

9. Clinical Manifestations
Signs
• Tachycardia
• Dry mucous membrane / decreased skin
turgor
• Dehydration / Hypotension
• Tachypnoea / Kussmaul breathing
• Abdominal tenderness
• Fever
• Lethargy / Obtundation / Coma

10. Lab Evaluation
• Random blood glucose,
• Urine ketones(dipstix)
• ABG
• Serum electrolytes
• Renal Function test
• CBC
• Cultures - Urine, Blood, Throat
• X-Ray Chest

11. Lab Evaluation
• Bicarbonate - <18 mEq/L
• pH - < 7.3
• Calculated anion gap – increased (High AG)
(Na + K) - (Cl + HCO3) Normal 10 ± 2
• Plasma ketones (1:2)/ Urine ketones - + + + +

12. Lab Evaluation
• Plasma Osmolality - 300 - 320 mOsm/L
• Creat / BUN - slightly increased
• Others-
Hyperamylasemia,hypertriglyceridemia

13. Differential Diagnosis
• Ketoacidosis
– Starvation ketosis
– Alcoholic ketoacidosis
• Lactic acidosis
• CRF
• Drugs & toxins
Salicylates, Methanol / Ethanol, Ethylene
Glycol, Paraldehyde

14. Treatment
Goals
• Improve circulatory volume
• Correct electrolyte imbalance
• Control blood glucose
• Identify and treat precipitating factors

15. Deficiency
• Water-100 ml/kg
• Na+ 5 meq/kg
• K + 4 meq/kg
• Cl- 3 meq/kg
• PO4 –2 meq/kg

16. Fluid Therapy
• Normal saline – 1 litre in 30 in min,
1litre in next 1h,
1 litre in 2h
• Subsequently 4 - 14 ml/kg/hr
– monitor fluids with hydration, urine output,
electrolytes
– 0.45 N saline if Na high
– Glucose < 250 mg%, use 5% dextrose + NS

17. Potassium
• Insulin drives potassium intracellularly.
• In an already depleted state Insulin may
precipitate significant hypokalemia.
• Serum K+ >5.5 meq/l. Start Insulin
3.3-5.5 meq/l-KCL 40meq/l,@ 20meq/h
+ Insulin
<3.3 meq/l –Withhold Insulin .KCL 60
meq/l @ 20 meq/l peripheral line
• KCl and KPO4 @ 2 : 1 may be given

18. Insulin
• Plain Insulin bolus - 0.15U/Kg
( 6-10 U) IV
• Insulin Infusion - (0.1- 0.2 U/kg/hr)
• Hourly glucose monitoring
• Glucose decreases by 40 - 60 mg/dl/hr
• If fall not adequate, check hydration, position of
catheter.

19. Insulin
• If hydration adequate, double Insulin infusion
• When glucose < 250 mg/dl,replace normal saline with
isotonic glucose saline
– Insulin Infusion 3 U/hr
• Maintain sugar between 140 - 200 mg%
• Subcutaneous Insulin to be started
patient able to take oral feeds
Anion gap is corrected
Acidosis is corrected
Bicarbonate is normalized
• Overlap between iv and sc insulin

20. Bicarbonate Infusion
• pH < 6.9 – 100 meq of Soda Bicarbonate in
400 ml sterile water @ 200 ml/hr
• pH 6.9-7- 50 meq of Soda Bicarbonate in
200 ml sterile water @ 200 ml/hr

21. Supportive Therapy
• Antibiotics
• Gastric decompression
• Anticoagulants if bed bound.

22. Complications
• Hypoglycemia - Overdose of Insulin
• Hypokalemia - large dose of insulin without
treatment of hypokalemia
• Hyperchloremia - excess Normal saline
• Persistent Ketosis - Premature reduction in
Insulin dose
• Cerebral oedema

23. Prevention
• Prevent Infection
• Education
– Insulin
– early warning signs
– diet
• Health education

24. Hyperosmolar hyperglycemic state
• Type 2 DM
• Elderly
• High mortality (approx 15% )
• Salient features
• Clinical features
Polyuria
Orthostatic Hypotension
Tachycardia
Severe dehydration
Neurological features, seizures,stroke

25. Clinical Features
Laboratory
- Plasma glucose > 600 mg/dl
– Plasma osmolarity >320 mOsm/kg
– HCO3 > 15 mmol/L
– pH > 7.3

26. Management
• Fluids - 1 - 3 l normal saline over 2 - 3 hrs,
9 - 10 l over 1 - 2 days ( avoid very rapid
reversal of hyperosmolar state)
• Insulin - 5 - 10 U bolus, 3 - 7 U/hr infusion
• Supportive care

27. Hypoglycaemia - Precipitants
• Mistimed / wrong dose of insulin
• Inadequate food intake (patient on sulphonylurea or
Insulin
• Exercise
• Alcohol intake
• Chronic Kidney Disease

28. Hypoglycaemia
Definition BG <40 mg/dl, symptoms ,symptom
relief with glucose (Virchow’s Triad)
BG mg/ dl Effect
69 Secretion of glucagon & adrenaline
55 Onset of autonomic symptoms
51 Neuroglycopaenia & cognitive
impairment
<18 coma

29. Hypoglycaemia …
Autonomic
Symptoms
sweating, pounding chest
hunger, anxiety, trembling
Signs
diaphoresis, pallor,
HR, bounding pulse, BP
tremors

30. Hypoglycaemia C/F …
Neuroglycopaenic
Symptoms
confusion, drowsiness
speech defect, incoordination
Signs
drowsiness – coma
dysarthria / aphasia
anger / violent behaviour
cognitive impairment
diplopia / hemiparesis

31. Management
• Suspect ,perform blood glucose using glucometer
• Administer Oral glucose
• IV 50% Dextrose 20 – 50 ml, followed by 10%
Dextrose by infusion
• Inj Glucagon 1mg IM / SQ
• If there is delayed recovery of consciousness post
hypoglycemia suspect
post-ictal phase / Intracerebral hemorrhage

32. Prevention
• Identify cause
• Rule out CKD
• Modify doses of medication
• EDUCATE

33. Differential Diagnosis
DKA Hypoglycemia HONK
History Warning signs sudden onset Sub-acute
Cl symp Pain Abdo Neuro symp Polyuria
Nausea, Adrenergic Ortho hypo
Vomiting Neuro
Patient Young any age Elderly
Pulse Rapid Bounding Low vol
low vol

34. Differential Diagnosis
DKA Hypoglycemia HONK
BP Low High Orthostatic
hypotension
Skin Cool Warm Cold,
moist clammy
Breath Fruity inc RR Kussmaul
Response Nil Improve Nil
to 50% D

35. Differential Diagnosis
DKA Hypoglycemia HONK Lactic Acidosis
B. glucose 300 - 600 Very low600 - 1200 Mild Inc
U. ketones ++++ Nil + / - Neg
U. Glucose ++++ Nil ++++ Neg
pH 6.8 - 7.3 N > 7.3 6.8 - 7.3
Anion gap Inc (10 - 12) N N / Mild inc Inc (10 - 12)

36. Hypoglycaemia - Precipitants
Accelerated insulin absorption
 mistimed / wrong dose of insulin
 inadequate food intake
 exercise
 alcohol / anorexia nervosa
 renal failure
 factitious

37. DKA - Introduction
Major cause of death in Type I diabetics <20 yrs age
Each episode – mortality 5 – 10 %
Main cause
Insulin Lipolysis
+
Glucagon Ketogenesis

38. Uncontrolled Diabetes
Lack of Insulin
anabolism Glucagon
Catechols
GH
Cortisol
Catabolism
Hyperglycaemia
Glycosuria
Osmotic diuresis
Hyperketonemia
Acidosis
Salt & water
DKA
Death
Glycogenolysis
Gluconeogenesis
Lipolysis

39. MONITORING
Routine
 Blood glucose q h
 Electrolytes, urea, pH, acid – base balance
 Ketones daily
 Urine output
 Consciousness level
Watch for
 Cerebral oedema (IV Mannitol)
 Respiratory distress (ventilation)
 Gastroparesis (nasogastric tube)
 Occult infection (broad-spectrum antibiotics)

40. Hyperosmolar Hyperglycemic state
Occurs in elderly DM 2
Precipitated by MI / infection / stroke /
thiazides / steroids
Gross ketonemia & acidosis lacking

41. Hyperosmolar Hyperglycemic state
Metabolic abnormality
sev hyperglycaemia (> 50mmol/L)
pre-renal azotemia
hypernatraemia >155mmol/L
hyperosmolality >350 mOsmol/Kg
Clinical features
intense thirst, polyuria, wt loss
blurred vision, drowsiness coma

42. Hyperosmolar Hyperglycemic state
Treatment
Similar to DKA
Insulin requirement usually only ½ of DKA
0.45% Saline if Na+ > 150mmol/L or plasma
osmolality >350 mOsm/Kg
Potassium replacement
Heparin 5000U SQ q 6h

44. Potassium replacement
Ser K+
5.5mmol/L No KCl
3.5 – 5.5 20 mmol KCl /L IV fluid
<3.5 40 mmol KCl /L IV fluid

45. THANK YOU