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Diabetic
complications -diabetes
can affect many organs and cause problems on many different levels.
Retinopathy is a leading cause of vision loss, renal failure, neuropathy
can cause problems with painful extremities, loss of sensation allowing for
diabetic foot complications, and also autonomic problems leading to orthostatic
changes along with poor motility in the GI tract.
Macrovasular complications include increased risk of stroke, peripheral
vascular disease and heart attack. -hyperglycemic
crisis can occur in both type1 and type 2 diabetics: 1.
Diabetic ketoacidosis (DKA): results
from insulin deficiency so most commonly occurs in type 1 diabetics.
Type 2 diabetics can also present with DKA. DKA is diagnosed when patients present with wide anion gap
metabolic acidosis, hyperglycemia and ketonemia and/or ketonuria. The lack of
insulin leads to a disruption in the balance of the counterregulatory hormones
including glucagon, epinephrine which leads to worsening hyperglycemia.
Once diagnosis of DKA is made the initial treatment (prior to insulin
therapy) is fluid resuscitation with an isotonic fluid (normal saline).
Avoid giving insulin prior to knowing the potassium since the osmotic
diuresis caused by glucosuria can lead to low levels of potassium along with
other electrolytes. Typically
regular insulin is given as an IV drip 0.1 units/kg bolus followed by 0.1
units/kg per hour drip until the acidosis resolves and then subcutaneous insulin
is started being careful to give the subcutaneous regular insulin at least 30
minutes prior to stopping the insulin drip to avoid a period when there is no
insulin coverage. Patients who
present with DKA need to be evaluated for the cause.
Most common causes include non-compliance, infection, or cardiac event.
2.
Nonketotic Hyperglycemia (hyperosmolar nonketotic coma):
These patients are usually type 2 diabetics.
Patients typically do not become acidemic because there is still insulin
present to prevent a large disruption in the balance between insulin levels and
the counterrugulatory hormones. Glucose
levels are typically higher than those seen in DKA and the course is usually
more insidious. The high osomolar
state can lead to alterations in mental status.
Treatment and workup are essentially the same as with DKA with hydration
being the first step. -The
metabolic syndrome (insulin resistance syndrome or formally known as syndrome
X): seen in obese patients (usually
those with abdominal obesity) with associated resistance to peripheral insulin
effects. Hypertension, diabetes,
dyslipidemia, and abdominal obesity make up the quartet of findings with the
metabolic syndrome. As would be
expected these patients are at higher risk for cardiac events.
Acanthosis nigracans (skin rash seen in diabetics) and skin tags are
commonly associated with insulin resistance.
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