Diabetes Mellitus

1. Diabetes Mellitus

2. Physiology of Energy Metabolism • All body cells use glucose for energy. • To maintain this constant source of energy, blood glucose levels must be kept between 3.3-6.1 mmol/L. • Several hormones, help to maintain this level between 3.3-6.1mmol/L, include insulin, glucagon. • The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver. The glucagon is released when blood glucose levels decreased (e.g. between meals and over the night) and stimulate the liver to release stored glucose.

3. Insulin • Diabetes is a disease which deals with insulin. • A healthy pancreas releases 40-50 units of insulin daily, still keeping several hundred units available in storage to be released if the blood glucose levels rise. • When insulin enters the bloodstream, it binds to insulin receptors on the membranes of the liver, muscle, and fat cells. In these cells, insulin encourages glucose uptake by causing a shift of another insulin sensitive glucose transporter, GLUT 4, to the surface of cells.

4. Pathophysiology of Diabetes Mellitus • Diabetes mellitus is not a single disease but a complex syndrome characterized by hyperglycemia resulting from altered carbohydrate, fat, and protein metabolism. • This altered metabolism is secondary to insulin insufficiency, insufficient insulin activity, or both. • Because of the altered fuel metabolism, diabetes is characterized by vascular and neurologic changes throughout the body. • Absence of insulin or ineffective insulin activity prevents glucose from entering liver, muscle and fat cells

5. Pathophysiologyof Diabetes Mellitus • As the blood glucose level approaches 10mmol/L, the ability of the kidney to reabsorb glucose is surpassed, and glucose is excreted into the urine. • Because it is an osmotic diuretic, glucose causes the osmosis of large amounts of water and electrolytes into the tubules, causing frequent urination in large quantities (polyuria), notably at night (nocturia). Dehydration, hunger, and fatigue follow.

6. Classical manifestations of diabetes • Polyuria – increased urination • Polydispia – increased thirst, which occurs as a result of excess loss of fluid associated with osmotic diuresis. • Polyphagia – increased appetite which results from the catabolic state induced by insulin deficiency

7. Types of diabetes • Type I • Type II • Gestational diabetes

8. Type I • This is characterized by the destruction of the pancreatic beta cells and early onset • The destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver and fasting hyperglycemia. • Glucose derived from food is not stored in the liver but remains in the blood stream and contributes to postprandial (after meals) hyperglycemia .

9. S&S • Increased thirst • Frequent urination • Fatigue • Excessive weight loss • Nausea and vomiting • Having dry, itchy skin • Feeling of numbness and tingling in the feet • Blurry eyesight • Constant hunger • Abdominal pain if DKA (Diabetic Ketoacidosis) have occurred

10. Type II • This the most common form of diabetes, often associated with older age, obesity, family history of diabetes e.t.c. • In type 2 diabetes, the pancreas is usually producing enough insulin, but for unknown reasons the body cannot use the insulin effectively, a condition called insulin resistance. After several years, insulin production decreases. So thus glucose builds up in the blood and the body cannot make efficient use of its main source of fuel • These patients are not prone to the development of DKA.

11. S & S • Fatigue • Frequent urination • Increased thirst and hunger • Blurred vision

12. Gestational diabetes • Gestational diabetes is a type of diabetes that occurs in non-diabetic women during pregnancy. It is any degree of glucose intolerance with its onset during pregnancy or late in pregnancy. This form of diabetes usually disappears after the birth of the baby.

13. Risk factors of gestational diabetes • Over the age of 30 • Obesity • Family history of diabetes • Having previously given birth to a very large child (over 9 pounds, 14 ounces), having previously given birth to a stillborn child or a child with a birth defect • Having too much amniotic fluid • Having gestational diabetes in a previous pregnancy • Having high blood pressure

14. S & S • Generally, gestational diabetes may not cause any symptoms; however, the woman may experience • Excessive weight gain, • Excessive hunger or thirst, • Excessive urination • Recurrent vaginal infections

15. Diagnosis of diabetes DM is indicated by typical S&S and confirmed by measurement of plasma glucose. • Fasting plasma glucose (FPG): measurement after an 8-12h fast. • Oral glucose tolerance testing (OGTT): 2h after ingestion of a concentrated glucose solution. OGTT is more sensitive for Dx DM and impaired tolerance but is more expansive and less convenient and reproducible than FPG. It is rarely used routinely, except for Dx of gestational DM. • HbA1c : testing for glycosylated hemoglobin. HbA1c levels reflect glucose control over the preceding 2-3 months. HbA1c is not considered as reliable as FPG or OGTT testing for Dx DM and used mainly for monitoring DM control.

16. Diagnosis of diabetes (con’t) Diagnostic criteria for DM and impaired glucose regulation

17. HbA1c • Glucose sticks to the haemoglobin to make a ‘glycosylated haemoglobin’ molecule, called haemoglobin A1c or HbA1c. • The more glucose in the blood, the more haemoglobin A1c or HbA1c will be present in the blood. • Red cells live 120 days before they are replaced. By measuring the HbA1C it can tell you how high your blood glucose has been on average over the last 8-12 weeks. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is good. • The HbA1C test is currently one of the best ways to check diabetes is under control; the HbA1C is not the same as the glucose level.

18. Management of Diabetes

19. Good Diabetes Management Regular Blood Glucose Monitoring Healthy Nutrition Regular Exercise

20. Nutrition • There isn't one "diabetes diet." •  The amount of food you can eat daily depends on: • Age • -Body size • -Activity level • -Gender • -Pregnancy or breastfeeding • Meal plan should be individualized for each client • With the help from a dietician, a diet is planned based on the recommended amount of calories, protein, carbohydrates, and fats. • A meal plan is a guide that tells you what kinds of food you can choose at meals and snack time and how much to have. For most people with diabetes (and those without, too), a healthy diet consists of 40% to 60% of calories from carbohydrates, 20% from protein and 30% or less from fat.

21. Nutrition (con’t) • 1500-1800 calorie is the ideal of amount that diabetes diet should have. This should include simple and healthy foods like whole grains, vegetables, fruits, low fat meats, non-fatty dairy products and fish but avoid foods like pastries, candy bars and pies. Note: • This does not include people, like pregnant women, those with eating disorder and children under 16 should seek medical advice before modifying their diet to adopt 1500-1800 calorie diabetes diet. • Carbohydrates (50-55% of energy), like whole grains, fruits, vegetables, milk, high fiber foods. • Proteins (15-20% of energy). • Fat (<30% of energy) • Example of 1500 calorie diabetes diet: 6 oz. lean meat/protein 6 servings bread/starch 4 servings fruit 5 or more servings vegetables 2 servings dairy (low fat preferred) 3 servings fat

23. Exercise • Exercise: Before diabetic patients engage in exercise program, they should consult with their healthcare provider because they need to have a complete history and physical examination • Exercise includes anything that keeps them move • Exercise (total of about 30 minutes a day, at least 5 days a week) lowers blood sugar levels by improving cell uptake of glucose, causing the body to process glucose faster.

25. Oral Anti-diabetic Agent • Biguanides-Metformin (Glucophage) Lowers glucose by decreasing liver glucose release and by decreasing cellular insulin resistance • Alpha-Glucose Inhibitors: (Precose)-Slows digestion and absorption of carbohydrates to maintain normal blood glucose levels. • Meglitinides: (Prandin)-Stimulates pancreas to secrete insulin • Thiazolidinediones: (Avandia, Actos)-Increases insulin sensitivity at receptor sites on liver, muscle, and fat cells. The medication works by helping make your cells more sensitive to insulin. The insulin can then move glucose from your blood into your cells for energy.

26. Insulin

27. Methods of delivery insulin • Intravenous (IV) • Syringes (SC) • Pens • Jet injectors • Insulin pumps

28. Site Selection: Where can I give the Injections? • 4 major areas: • Arms-posterior surface • Abdomen-avoid 1 inch area around navel • Thighs-anterior surface • Hips Note: • Systematic rotation of injection sites within an anatomic area to prevent lipodystrophy. • Administering each injection 0.5-1inch away from the previous injection.

29. Storing and Handling Insulin • Stored at room temperature (15 to 30°C). • If stored in a refrigerator, unopened bottles are good until the expiration date printed on the bottle. • Opened bottles that are stored in a refrigerator should be used within one month of being opened. • Protect your insulin (bottles, pens, and cartridges) from extremes of hot and cold. • Never store your insulin in the freezer - once insulin is frozen, it loses its potency.

30. Diabetes Mellitus Case Study

31. Patient profile Name: J.P . Age: 68 Sex: Male Ethnicity: Algonquin Canadian Ht: 5’7” Wt: 276 lb (BMI 43.2, obese) Medical Hx: • Type II diabetes for 5 years • hypertension, A-fib • hypercholesterolemia • and chronic bronchitis Family Hx: • Father died of CVA. • Mother died of End-stage renal failure due to complications of diabetes. Social Hx: • Elderly, lives alone • Sedentary lifestyle • Poor understanding of diabetes and non-compliance of medication

32. Risk factors for diabetes Being: • A member of a high-risk group (Aboriginal, Hispanic, Asian, South Asian or African descent) • Overweight, or obese Having: • A parent, brother or sister with diabetes • Health problems e.g. renal, hepatic… • Given birth to a baby that weighed more than 4 kg (9 lb) • Had gestational diabetes (diabetes during pregnancy) • Impaired glucose tolerance or impaired fasting glucose • High blood pressure • High cholesterol or other fats in the blood

33. Assessments on arrival in ER V/S: T: 38.5°C ; HR: 145bpm; RR: 21; BP: 80/45 mmHg (lying) SaO2: 88% RA CBG: 34.0 mmmol/L Integumentary: poor skin turgor, cracked lips and very dry mucosa membrane; very dry and flaky skin on both feet and up to knees, the skin on the lower leg and feet is red and shiny in characteristics. One pea-size lesion on the side of baby toe of right foot. Mental Status: Lethargy, confused and disoriented, audio and visual hallucination poor on people, place and time. Neurology: unable to feel left side of body, sensation of right side of body present. c/o dizziness and mild generalized headache. Blurry vision. Pulmonary: respiration shallow. Lungs clear. Decreased AE to both lower lobes of lungs. Cardiovascular: rapid, thready and irregular pulse, cool extremities; peripheral pulses present and weak. GI: Abd distended and firm. No c/o pain on palpation. Decreased and faint bowel sounds . Last BM unknown. **Doctor ordered diagnostic tests: CT scan of brain, Cardiac marks, BUN, Creatinine, Chemical Routines, Electrolytes, CBC, and UA STAT.

34. Selected Lab Values

35. Acute Complications of Diabetes Mellitus

36. Acute complications of diabetes • Hypoglycemia • Hyperglycemia • DKA • Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

37. Hypoglycemia • Hypoglycemia can result from Skipping meals, an excess of either insulin or oral diabetes medication. • CBG 2.7-3.3mmol/L • Usually, hypoglycemia can be managed by consuming a sugar product or fruit juice. • Most hypoglycemic reactions are mild, and people with diabetes and their families are trained to recognize them and self-administer the sugar needed to correct the situation. • In the case of severe low blood sugar resulting in coma the use of glucagon and/or the assistance of a health professional may be required.

38. Management of Hypoglycemia • Patient should recognize s&s of hypoglycemia (sweating, shaking, weakness, hunger, nausea, irritability and confusion) and know what to do when it strikes • In case of hypoglycemia, the patient should drink a glass of orange juice/regular soft drink, two packets of sugar, or 5 or 6 hard candies. • If the symptoms are still present after 10-15 minutes, patient should be given again another glass of orange juice. • Once the symptoms have improved, the patient should eat longer lasting carbohydrate such as bread or milk.

39. Management of hypoglycemia • SC or IM Glucagon or IV dextrose is administered (Unconscious Patients/Unable to Swallow) • Note: High-fat foods and high-protein foods should not be used initially to correct hypoglycemia. These food sources are metabolized too slowly to be effective as immediate treatment.

40. Hyperglycemia • Patient should recognize symptoms of hyperglycemia (high blood sugar): blurred vision, excess thirst, frequent urination, and nausea…etc. • Hyperglycemia develops when there is too much glucose, not enough insulin or insufficient insulin activity in the blood stream.

41. Hyperglycemia Gastrointestinal absorption of glucose Impaired insulin secretion Pancreas HYPERGLYCEMIA Liver Muscle Increased basal hepatic glucose production Decreased insulin-stimulated glucose uptake

42. Management of Hyperglycemia • Rehydration-if dehydrated, drink plenty of water. • Oral anti-diabetic agent • Insulin

43. Diabetic ketoacidosis (DKA) • This is a life threatening disease caused by the absence of insulin, which results in disorders in the metabolism of carbohydrates, fats, and proteins • Most often occurs in type I diabetes

44. Sequence of events • Serum glucose level rises because most tissues cannot utilize glucose without insulin • The high osmotic pressure created by excess glucose leads to osmotic diuresis • Polyuria occurs • The sympathetic nervous system responds to the cellular need for fuel by converting glycogen to glucose and manufacturing additional glucose • As glycogen stores are depleted, the body begins to burn fat and protein for energy • Fat metabolism produces acidic substances called ketone bodies which accumulate and lead to metabolic acidosis • Protein metabolism results in the loss of lean muscle mass and a negative nitrogen balance.

45. S&S for DKA • The individual with DKA has hyperglycemia, ketonuria, and acidosis with a pH of less than 7.3 or a bicarbonate level of less than 15mmol/L • Early signs of DKA are anorexia, headache and fatigue. As the condition worsens the classic signs of polyuria, polydipsia, and polyphagia occurs. • If untreated, the individual becomes dehydrated, weak, lethargic with abdominal pain, nausea and vomiting, fruity breath, increased respiratory rate, tachycardia, blurred vision and hypothermia. Late signs are air hunger, coma, shock and death

46. Assessments • Blood glucose test (varies from 16.6 to 44.4mmol/L) • Blood and urine ketone measurements • Arterial blood gas analysis

47. Treatment • It is aimed at the correction of the three main problems: • Dehydration, • Electrolyte imbalance, • Metabolic acidosis.

48. Hyperosmolar Hyperglycemia Nonketotic Syndrome (HHNS) • Is a condition whereby hyperosmolarity and hyperglycemia predominates with alteration in sensorium. • The basic defect is lack of effective insulin. The individual persistent hyperglycemia causes osmotic diuresis and glucosuria, dehydration, hypernatremia and increased osmolarity occurs. • This condition occurs in the elderly with history of, or undiagnosed type 2 diabetes. • In this situation there is insulin present but the level of insulin is enough to prevent fat breakdown but not enough to prevent hyperglycemia, thus there is no production of ketone bodies and no ketoacidosis.

49. Manifestations • Profound dehydration, poor skin tugour, tachycardia and alteration in sensorium • Assessments include: - Blood glucose levels - Electrolytes - BUN - Complete blood count - Serum osmolarity - Arterial blood gas analysis - Mental status changes

50. Comparison of DKA & HHNS