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Acute Emergencies and Chronic Complications of Diabetes - Coggle Diagram
Acute Emergencies and Chronic Complications of Diabetes
DKA
Insulin deficiency + excess counter regulatory hormones
Decreased peripheral glucose utilizaton, glucose production increase
Increase lipolysis in adipocytes -> Increase free fatty acid release
Increase in glycerol -> Increase in ketogenesis
Increase in acetyl-CoA production
Acetyl-CoA increases substrate for hepatic synthesis of ketone bodies
Precipitants
Initial diagnosis, Insulin omission, infection, ischemia, intra-abdominal process
Symptoms
Volume depletion: Polyuria, Polydipsia, Weight loss
Diagnostic Criteria
Hyperglycemia (>14 mmoL)
Positive serum Ketones (elevated serum heta hydroxybutyrate)
Metabolic Acidosis (Elevated anion gap >12 mmol/L), pH <7.3
Treatment
Monitored: ABCs, IV access, replace volume loss, replace potassium, stop ketone production, correct acidosis, monitor labs, treat underlying cause
Volume resuscitation (IV crystalloid)
Potessium (Add if serum 5.5 mmol/L)
Insulin infusion (DO not stop until anion gap is closed)
Diabetic Retinopathy
Common cause of legal blindness in working age, associated with signifcant morbidity (falls, hip fractures, mortality), linked to duration and severity of hyperglycemia
Stages: Background, pre-proliferative, proliferative
Background: Microaneurysm and hemorrhages (increase capillary permeability), retinal edema leads to hard exudates
Pre-proliferative retinopathy: Dilated irregular veins, intraretinal microvascular changes, large blot hemorrhage
Proliferative Retinopathy
Retinal Ischemia: promotes proliferation, vessel growth, new vessels lack support easily bleed, retinal detachment and blindness
Diabetic Neuropathy: Distal Symmetric
Usually sensory, small or fiber involvemnt, may be acute (rare), or chronic (common)
Increased risk of foot ulcers, amputations
Autonomic Neuropathy
Cardiovascular: Resting sinus tahcycardia, exercise intolerance, orthostatic hypotension
Gastrointestinal: Automatic gastropathy, delayed gastric emptying, diabetic diarrhea
Genitourinary: Erectile dysfunction, bladder dysfunction
Testing
10 gram monofilmanet testing, 128Hz tuning fork
Hyperosmolar Hyperflycemic State (HHS)
Severe Hyperglycemia, Lack of significant ketosis, sever volume contraction, serum hyperosmolarity, precipitants similar to DKA
Treatment: Volume resuscitation, correct hypernatreamia, usualyl does not require insulin infusion (typically hyperglycemia is from severe volume contraction)
Hypoglycemia
Whipple's Triad: (Glucose <4.0 mmol/L), symptoms (autonomic, neuroglycopenic), Symptoms resolve after administering glucose
Symptoms
Autonomic (diaphoresis, tremor, palpitations, anxiety)
Neuroglycopenic: Confusion, seizure, loss of consciousness
Hypoglycemia unawareness: Can occur with repeated symptoms, and decreased/absent autonomic symptoms, risk of severe hypoglycemia
Treatment
15 gram of glucose, chekc sugars after 15 min
Complications Theories
Hyperglycemia
Aldose Reductase pathway: Glucose converted to sorbitol which alters redox potential to increase cellular osmolarity, increased reactive oxygen species
Non-enzymatic glycosation: Interaction of glucose with amino acids (reversible)
Advanced Glycosylation: Longer term exposure to hyperglycaemia leads to cross-links, receptor interactions, accumulate and attract macrophages
Endproducts: Levels occur with diabetes, age, smoking, and renal dysfunction
Cross-linked proteins: Recognized by macrophages, induce leaky endothelium, potent chemotaxic agent, promote growth factor release
Reactive Oxygen Intermediate Theory
Increased oxidative stress (Decrease nitric oxide levels), damages cellular proteins, promotes leukocyte adhesion to endothelium
Protein Kinase C
Glycolysis products activate PKC
Alters gene transcription for fibronectin, Type IV collagen, contractile proteins, extra-cellular matrix proteins
Diabetic Nephropathy
Risk Factors: Duration of diabetes, male, A1C above target, Hypertension, Obesity, smoking
Structural changes in glomerulus: Extracellular matrix, basement membrane thickening, mesangial expasion, fibrosis,
Lead to leaky filtration membrane: Increased filtration, damage to renal tubules, loss of nephrons
Decreased GFR -> Leads to albuminuria
Screening
Random Urine albumin-creatinine ratio (uACR)
Test of Choice, require persistent elevation
24 Hr urine creatinine clearance, albumin, protein (Gold Standard but cumbersome)
Creatinine, eGFR
Preventing Development
Glycemic Control, BP <130/80, Diabetes pharmacotherapy, Manage CV risk factors, smoking, dyslipidemia, weight
Macrovascular Disease
Coronary Artery Disease
Leading cause of death in type 2 diabetes, high incidence in type 1 diabetes
Cerebrovascular Disease
Peripheral Vascular Disease
Diabetes: increased frequency of severe
Particularly in lower extremities, risk of ischemic ulcers amputations
Risk of Ischemic Ulcers, and amputations
Pedal Pulses
Diabetic Ulcers: Commonly found in balls of feet, impaired healing due to peripheral vascular disease, neuropathy: impaired sensation