DIABETIC COMPLICATIONS

ACUTE MEDICAL CONDITIONS ASSOCIATED WITH DIABETES

Diabetic renal disease: one-third of Type I and between one-quarter and one-half of Type II diabetic patients develop diabetic kidney disease (diabetic nephropathy).

Urinary protein loss is often the first indication of renal disease. An early sign that diabetes is affecting the kidneys is the presence of "micro" albuminuria - a loss of 30-300 mg per 24 hours - which can be detected using a specialised screening test.

-Proteinuria indicates probable renal involvement.

-Proteinuria goes hand-in-hand with cardiovascular complications and diabetic eye disease.

-Proteinuria is strongly associated with hypertension.

-Switching off the renin-angiotensin-aldosterone system with ACE inhibitors or angiotensin II receptor blockade slows down the deterioration from microalbuminuria to advanced diabetic nephropathy.

Important tasks if diabetic renal disease is discovered: careful blood pressure control, treatment with ACE inhibitors and related drugs, tight diabetic control, correction of lipids and advice on cessation of smoking.

Diabetic neuropathy: diabetic nerve damage is very common - it occurs in around one-third of patients with type II diabetes. There are two types of diabetic neuropathy:

-Peripheral neuropathy: it gives problems on the feet (numbness, poor skin nutrition and impaired mobility). The patient has no warning of trauma to the feet, nerve damage and muscle imbalance lead to foot deformity and pressure damage over abnormal bony prominences. Elsewhere in the body, nerve damage can lead to neuralgia with severe, recurrent and often undiagnosed pain in the thighs and abdomen.

-Autonomic neuropathy: it leads to abnormal regulation of involuntary muscle activity, notably in the bladder (painless retention, overflow and recurrent urinary infection), in the control of the blood pressure (severe postural hypotension) and in gastric emptying (regurgitation and aspiration of the stomach contents).

Cardiovascular disease: the main manifestations of cardiovascular disease are angina, myocardial infarction and heart failure.

Cerebrovascular disease: the vascular damage in diabetes affects both the larger cerebral vessels and the cerebral microcirculation. Diabetic cerebrovascular disease presents with typical stroke-like symptoms due to thrombosis or hypertension-related cerebral haemorrhage. It should be assumed that any change in the consciousness level of a diabetic patient has a metabolic cause until proved otherwise.

Peripheral vascular disease: it presents as an emergency with ischaemic problems in the limbs due either to acute arterial occlusion or to vascular complications in the feet: ulceration, infection and gangrene.

*The DIGAMI regimen: an example of controlling the blood sugar in acute illness. Click here.

MANAGEMENT OF ACUTE DIABETIC EMERGENCIES

DKA (Diabetic Ketoacidosis)

Causes: infection, disruption of insulin treatment, new-onset diabetes, etc.

Underlying mechanism: in DKA there is an acute shortage of insulin. As a result, the liver produces and releases excessive amounts of glucose that appear in the blood and in the urine. The heavy glucose load in the urine pulls in water and electrolytes by osmosis, leading to losses of fluid, potassium, sodium, phosphate and magnesium. Because there is shortage of insulin, sugar cannot enter the cells and so the body starts to burn adipose tissue as an alternative energy source. The adipose tissue breaks down to free fatty acids, which are converted into ketones by the liver. Ketones are acidic substances, so when excess ketones appear in the blood they produce an acidosis.

Management: adequate insulin replacement and correction of fluid and electrolyte loss.

Critical nursing tasks in DKA:

-Observations: oxygen saturation, blood sugar, blood pressure, pulse (ECG), temperature and respiratory rate.

-Glasgow Coma Score.

-Test for urinary ketones.

-Examine for signs of infection.

-Ensure that the initial infusions are correctly prescribed and administered.

-Monitor patient´s progress and address his/her physical needs.

-Provide reassurance and support, initiate plans to prevent this from happening again.

Hyperosmolar Non-Ketonic Diabetic Coma (HONK)

This relatively rare complication is seen in the elderly Type II diabetic patients, the patient presents extremely unwell, with very high blood sugars and impaired consciousness levels, but without ketoacidosis. They are usually profoundly dehydrated due to osmotic fluid loss. The history usually involves a precipitating illness.

The diagnosis is made from the clinical setting and the finding of a high blood osmolality.

Management: CVP monitoring, nasogastric intubation to prevent aspiration and judicious fluid therapy.

As the sodium levels are usually very high, hypotonic saline (0.45%) can be used in place of the initial isotonic saline.

Because the blood is so concentrated, the patients are at great risk of thrombosis and should be anticoagulated.

Hypoglycaemia.
Symptoms: click here .
Management:
-If the patient is conscious and cooperative: 100ml Lucozade, 6 glucose tablets or four teaspoonfuls of sugar.
-If there is an impaired consciousness level: intravenous glucose or intramuscular glucagon.

Infective complications in diabetes: the acute diabetic foot.

The severily infected foot that brings the diabetic patient in as an emergency will characteristically have cellulitis spreading from an area of ulceration. By the time the patient needs admission, the ulcer will have become infected and the whole foot may be at risk.