Diabetes Mellitus (cont.)
What are the acute complications of diabetes?
- Severely elevated blood sugar levels due to an actual lack of insulin or a
relative deficiency of insulin.
- Abnormally low blood sugar levels due to too much insulin or other
glucose-lowering medications.
Insulin is vital to patients with type 1 diabetes - they
cannot live with out a source of exogenous insulin. Without insulin, patients with type 1 diabetes
develop severely elevated blood sugar levels. This leads to increased urine
glucose, which in turn leads to excessive loss of fluid and electrolytes in the
urine. Lack of insulin also causes the inability to store fat and protein along
with breakdown of existing fat and protein stores. This dysregulation, results
in the process of ketosis and the release of ketones into the blood. Ketones
turn the blood acidic, a condition called diabetic ketoacidosis (DKA). Symptoms
of diabetic ketoacidosis include
nausea, vomiting, and abdominal pain. Without
prompt medical treatment, patients with diabetic ketoacidosis can rapidly go
into shock,
coma, and even death.
Diabetic ketoacidosis can be caused by infections,
stress, or trauma all which may increase insulin requirements. In addition,
missing doses of insulin is also an obvious risk factor for developing diabetic
ketoacidosis. Urgent treatment of diabetic ketoacidosis involves the intravenous
administration of
fluid, electrolytes, and insulin, usually in a hospital intensive care unit.
Dehydration can be very severe, and it is not unusual to need to replace 6-7
liters of fluid when a person presents in diabetic ketoacidosis. Antibiotics are
given for infections. With treatment, abnormal blood sugar levels, ketone
production, acidosis, and dehydration can be reversed rapidly, and patients can
recover remarkably well.
In patients with type 2 diabetes, stress, infection, and medications (such as
corticosteroids) can also lead to severely elevated blood sugar levels.
Accompanied by dehydration, severe blood sugar elevation in patients with type 2
diabetes can lead to an increase in blood osmolality (hyperosmolar state).
This condition can lead to coma (hyperosmolar coma). A hyperosmolar coma usually
occurs in elderly patients with type 2 diabetes. Like diabetic ketoacidosis, a
hyperosmolar coma is a medical emergency. Immediate treatment with intravenous
fluid and insulin is important in reversing the hyperosmolar state. Unlike
patients with type 1 diabetes, patients with type 2 diabetes do not generally
develop ketoacidosis solely on the basis of their diabetes. Since in general,
type 2 diabetes occurs in an older population, concomitant medical conditions
are more likely to exist, and these patients may actually be sicker overall. The
complication and death rates from hyperosmolar coma is thus higher than in DKA.
Hypoglycemia means abnormally low blood sugar (glucose). In patients with
diabetes, the most common cause of low blood sugar is excessive use of insulin
or other glucose-lowering medications, to lower the blood sugar level in
diabetic patients in the presence of a delayed or absent meal. When low blood
sugar levels occur because of too much insulin, it is called an insulin
reaction. Sometimes, low blood sugar can be the result of an insufficient
caloric intake or sudden excessive physical exertion.
Blood glucose is essential for the proper functioning of brain cells.
Therefore, low blood sugar can lead to
central nervous system symptoms such as:
The actual level of blood sugar at
which these symptoms occur varies with each person, but usually it occurs when
blood sugars are less than 65 mg/dl. Untreated, severely low blood sugar levels
can lead to coma, seizures, and, in the worse case scenario, irreversible brain
death. At this point, the brain is suffering from a lack of sugar, and this
usually occurs somewhere around levels of <40 mg/dl.
The treatment of low blood sugar consists of administering a quickly absorbed
glucose source. These include glucose containing drinks, such as orange juice,
soft drinks (not sugar-free), or glucose tablets in doses of 15-20 grams at a
time (for example, the equivalent of half a glass of juice). Even cake frosting applied
inside the cheeks can work in a pinch if patient cooperation is difficult. If
the individual becomes unconscious, glucagon
can be given by intramuscular
injection.
Glucagon causes the release of glucose from the liver
(for example, it promotes gluconeogenesis). Glucagon can be lifesaving and every
patient with diabetes who has a history of hypoglycemia (particularly those on
insulin) should have a glucagon kit. Families and friends of those with diabetes
need to be taught how to administer glucagon, since obviously the patients will
not be able to do it themselves in an emergency situation. Another lifesaving
device that should be mentioned is very simple; a medic alert bracelet should be worn by all patients
with diabetes.
Next: What are the chronic complications of diabetes? »
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