Flashcards in Diabetes Deck (130)
What causes diffuse neuropathies?
accumulation of fructose and sorbitol which disrupts the structure and function of the nerve
What are the different types of progressive neuropathy?
symmetrical sensory polyneuropathy (the most common form) and autonomic neuropathy
Symptoms of symmetrical sensory polyneuropathy?
affects the feet first, with loss of vibration, pain and temperature sensation and impaired proprioception
can lead to unrecognised trauma with vlistering leading to ulceration, neuropathic arthropathy in the ankle and knee causing a deforms and swollen joint
involvement of motor nerves can cause muscle wasting in the hand and a distorted foot with a hgih arch and clawing of the toes
Symptoms of autonomic neuropathy?
affects the CV (resting tachycardia, loss of sinus arrhythmia, postural hypotension), GI (diarrhea, gastroparesis), bladder (incomplete emptying) and erectile dysfunction
What are the different types of reversible neuropathy?
acute painful, mononeuropathy, mononeuritis multiplex, cranial nerve lesions, isolated peripheral nerve lesions, diabetic amyotrophy
Symptoms of acute painful neuropathy?
burning/ crawling pains in lower limbs, worse at night and pressure from bed clothes can be intolerable
Symptoms of mononeuropathy/mononeuritis multiplex?
where one of more nerves are affected, can be abrupt and painful lesions, more common at sites of external pressure, with pain, ptosis, diplopia and sparing of pupillary function
Symptoms of diabetic amyotrophy?
asymmetrical, painful wasting of the quadriceps, the wasting is marked and knee reflexes are diminished or absent
What foot damage can occur in diabetes?
ischemia and haemorrhage and tissue necrosis leading to ulceration, infections, gangrene, dcellulitis, abscess and osteomyelitis, bone deformity, absent dorsal pedis pulses
Prevention and treatment of feet in diabetes?
daily foot examination, comfortable shoes, no bare foot walking, regular chiropody to remove callus, relieve high pressure areas with best rest and therapeutic shoes, metatarsal head surgery, IV antibiotics for cellulitis, surgery if abscess or deep infection, good local wound care, reconstructive vascular surgery in area of arterial occlusion
What causes increased infections in diabetes?
impaired function of polymorphonuclear leucocytes particularly in urinary tract and skin, TB and mucocutaneous candidiasis are common, can leading to further loss of glycemic control and cause ketoacidosis
What effect does diabetes have on the skin?
lipohypertrophy, necrobiosis lipoidica deabeticorum (erytheatous plaques over the shins with a brown waxy discolouration), vitiligo (symmetrical white patches), granuloma annulare (flesh coloured rings and nodules over extensor surfaces of fingers)
How can lipohypertrophy be avoided?
varying the injection site of the insulin day to day
Prognosis of diabetes?
1 - good health, but increased risk of complications so must have good control, blood pressure and weight
2 - 75% die of heart disease, 15% of stroke, CV disease is 5x more common
for every 1% increase in HbA1c level there is an increase in death from diabetes by 21%
What is diabetic ketoacidosis?
hyperglycaemia (blood glucose >11mmol/L), acidaemia (pH3mmol/L) or significant ketonuria (>2 on urine stix)
When does ketoacidosis occur?
in starvation states, the body can no longer metabolize carbohydrates as the body is less efficient, there is excess glucose that cannot be taken up or metabolized due to lack of insulin so the body goes into starvation state for energy production, this produce acetone, increase in hepatic gluconeogensis, peripheral lipolysis increasing free fatty acids which is converted into acidic ketones
What increases the effect of and triggers ketoacidosis?
stress hormones (catecholamine, glucagon, cortisol) which are secreted in response to dehydration and intercurrent illness, infection, discontinuation or inadequate insulin, CV disease, steroids, menstruation, pancreatitis, chemo
In who is ketoacidosis seen?
in 4% of type 1 DM, especially in newly presenting, hospital patients, rare in DM 2 unless older, overweight, non white and newly presenting
Presentation of ketoacidosis?
polyuria, polydipsia, vomiting, dehydration, altered mental state, coma, weight loss, anorexia, weakness, lethargy, Kussmaul respiration (deep hyperventilaton) and acetone fruity breath
dry mucous membranes, dry tongue, decreased skin turgor/skin wrinkling/reduced tissue turgor, sunken eyes, slow capillary refill, tachycardia, weak pulse, hypotension
What will investigations show in ketoacidosis?
chest may have pneumonic consolidation, pericardial rub, murmurs, may have intra abdominal precipitant, altered mental status, abscess, boils, rashes
glycosuria and ketonuria, elevated glucose levels, ketonaemia, raised WCC, high sodium due to dehydration, hyperkalaemia due to acidosis, elevated urine and creatinine due to AKI
plasma osmolarity >290mOsm/kg
anion gap is >13mmol/L
How is plasma osmolarity calculated?
How is anion gap calculated?
DD of diabetic ketoacidosis?
alcoholic ketoacidosis, hyperosmolar hyperglycemic state, lactic acidosis, aspirin overdose, acute pancreatitis, sepsis without ketoacidosis, acute abdomen, ketoacidosis due to starvation
Management of diabetic ketoacidosis?
replace fluid, remove ketones, replace electrolyte loss, replace insulin, restore acid base balance, shift potassium back into cells, ABC, O2 monitor, ECG monitor, large bore peripheral IV access, urinary catheterisation to monitor urine output, LMWH and TED stockings, nasogastric tube if drowsy or vomiting, IV insulin infusion, 5% dextrose once glycemia is normal to prevent hypoglycemia, treat underlying cause, regular monitoring
What is classed as severe DKA?
1 of the following:
blood ketones >6mmol/L
bicarbonate 100 or 16
Who is DKA needs specialist input?
elderly, pregnant, 18-25, heart or kidney failure, serious comorbidities, fluid administration and deficits
Complications of DKA?
cerebral oedmea, headache, pulmonary oedema, hypoglycemia, arrhythmia, brain injury, death, hypokalaemia, metabolic acidosis, myocardial suppression, venous thromboembolism, MI, retinopathic changes, ARDS
Prognosis of DKA?
high mortality rate, but rates are decreasing, prognosis is worse with age and severe underlying causes, death mainly by cerebral oedema in the young and pneumonia, MI and sepsis in adults
Prevention of DKA?
good diabetic control, educate on risk factors and symptoms, monitoring, psychological support