Module 4

ACUTE COMPLICATIONS OF DIABETES

 Contents
Sr. No Title Page No.

1 Learnings from module 3 2

2 Role of diabetes educator 3

3 Complications of Diabetes 4

4 Acute Complications of Diabetes 5

• Hypoglycemia

• Hyperglycemia

5 Sick Day Management of Diabetes 19

6 Summary 22

7 Role plays 24

1
 1. Learnings from module 3

Insulin is needed for people with diabetes who cannot be managed on

oral anti-diabetic agents. There are short-, intermediate-, long-acting
conventional insulin and newer insulin preparation consists of rapid-,
long- and biphasic insulin analogue. Insulin is measured in units and
administered through syringes. Factors affects insulin dosage and its
action which includes time of administration, and storage. Insulin is
delivered through various devices such as pumps, pens and inhaler.

2
 2. Role of diabetes educator
The diabetes educator (DE) plays a pivotal role in management and
prevention of acute diabetic complications. He/she should guidance
and education to the patients, following are the roles of DE;
• To educate the patients about acute complications of diabetes
• To make the patients aware of the hazards of untreated acute
complications

• To help the patients in early recognition of the signs and symptoms

• To advise the patients on basic management of acute complications

• To recognize the patients at risk of acute complications

• To make the patients raise the red flag for seeking doctor's help

Introduction

Diabetes is a chronic metabolic disease causing acute and chronic

complications. The acute complications have a quick onset and need to
be managed immediately. It is important to know the precise
manifestations of the acute complications for early recognition
and prompt treatment. It is important to train the diabetes care
providers for correct diagnosis of these acute complications. Along
with this, the patient should also be made aware to identify the
symptoms of these complications. The patient and the provider should
be abreast with the basic measures required to manage these
complications. Therefore, it is important to be aware of the sick-day
management strategies. This module would give a detailed
understanding of the acute diabetic omplications along with the
methods of their diagnosis, management and preventive measures.

3
3. Complications of Diabetes

Diabetes complications

Acute (Short-term) Chronic (Long-term)

• Hypoglycaemia
• Diabetic ketoacidosis Microvascular Macrovascular
• Hyperglycaemic
hyperosmolar
syndrome • Neuropathy • Cardiovascular disease
• Nephropathy • Cerebrovascular disease
• Retinopathy • Peripheral vascular disease

Figure 1: Complications of Diabetes

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 4. Acute Complications of Diabetes

Hypoglycemia (Causes, symptoms, treatment, consequences)

• “Hypoglycemia” refers to abnormally low blood sugar level i.e. < 70
mg/dL.

• Hypoglycemia is a major limiting factor in the glycemic management of

type 1 and 2 diabetes.

• Hypoglycemia occur due to sudden drop in blood sugar levels and cells
do not get adequate glucose. It is also referred as 'insulin reaction' or
'insulin shock'.

• In individual taking insulin and/or insulin secretagogues, physical

activity can cause hypoglycemia if medication dose or carbohydrate
consumption is not altered.

• Every individual shows a different reaction to hypoglycemia and

therefore it important to understand hypoglycemic symptoms. 1-3

Risk factors
Hypoglycaemia is a preventable complication and it is important to identify
the risk factors that predispose an individual to a hypoglycaemia.

The risk factors of hypoglycaemia are as follows:

1. Not enough food intake, late or missed meal, fasting

2. Malnourishment

3. Excess insulin/Medication dose

4. Prolonged and unplanned physical activity

5. History of severe hypoglycaemia

6. Pregnancy

5
7. Inability to recognise symptoms (hypoglycaemia unawareness)

8. Long-standing diabetes

9. Disease conditions e.g., liver, kidney, gastrointestinal (GI) tract

10. Medications and alcohol

4,5
11. Erratic or altered absorption of food (diabetic gastroparesis)

Symptoms
The symptoms of hypoglycaemia are classified into mild, moderate and
severe. Mild symptoms can be managed by the patient, whereas moderate
and severe symptoms require medical help. 4,6 (Table 1)

Table 1: Symptoms of hypoglycaemia

Mild Moderate Severe
Capable of self-treatment May require prompting Not capable of self-treatment

Tremors, palpitation, Headache, dizziness, mood Conscious or unconscious,

sweating, hunger, fatigue, changes, low attentiveness, coma convulsions, disoriented
cold clammy skin drowsiness, blurred vision, behaviour
slurred speech

Night-time symptoms of hypoglycaemia

• Damp sheets or bedclothes due to perspiration

• Nightmares

• Irritability, tiredness or confusion on waking up

Hypoglycaemia unawareness
A healthy individual can easily recognize the warning signs and symptoms
of hypoglycaemia, however, this response is blunted in people with
diabetes . In type 1

6
diabetes and severely type 2 diabetes, hypoglycaemia
unawareness can severely compromise diabetes control and quality
of life. Hypoglycaemia unawareness is frequently encountered in patients
with:

• Recurrent hypoglycaemicepisodes

• Long-termdiabetes

• Aggressiveglycaemiccontrol

Management of Severe Hypoglycemia (Blood glucose <40 mg/dL)

• This debilitating disorder can be managed by ensuring that the person

has no hypoglycaemic episodes for a period of several weeks (average
6 weeks)

• There should be strict avoidance of low blood sugar levels

• Patients should be encouraged to test before engaging in any activity

that might put themselves or others at risk – such as driving a car

• For people living alone, there should be safety strategies in place (such
as sugar source placed at the bedside)

• Regular check-ups3,4,5

Consequences of hypoglycaemia
Hypoglycaemia has a number of social and health implications.
Hypoglycaemia can lead to injury, such as falling and fracturing bones;
accidents while driving; cognitive impairment and rarely death.
Hypoglycaemia and severe hypoglycaemia in particular, may be a major
limitation in achieving desired glycaemic goals.4 (Table 2)

7
 Table 2: Consequences of hypoglycaemia
Mild-Moderate Severe
• Fear • Injury
• Anxiety • Seizures
• Affects self-care • Transient paralysis
• Social stigma • Cognitive impairment
• Prejudice • Death

Management
H y po g ly c a e m ia t r e a t m e n t r e q u ir e s
inges tion of gluc os e or c arbohy drate
containing foods . Pure glucos e is the Rule of 15
preferred treatment, but any form of Take 15 g of glucose
carbohydrate that contains glucos ew ill Wait for 15 minutes
ra is e blood gluc os e lev el. G luc a gon If still low treat with
adminis tration is another method of another 15 g glucose
m a na ging hy pogly c a e m ia of s e v e re
nature.

Management of Mild or moderate hypoglycaemia

1. To give 15 g glucose; wait for 15 minutes and then check blood glucose
levels

• Glucose tablets or gel

• 1/2cup fruit juice

• 3/4cup soft drink

• 3 teaspoons sugar or honey

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2. If the blood glucose level is still <70 mg/dL or if the symptoms persist,
repeat the treatment

3. When the blood glucose level is >70 mg/dL, the symptoms have
subsided, and if meal/snack is not planned in the next 30 minutes, give
an extra snack of complex carbohydrate and protein

Management of Moderate hypoglycaemia

• Same as that for mild hypoglycaemia

• 30 g of fast acting carbohydrate may be required

Management of Severe (Bloodglucose <40 mg/dL)

• Glucagon (subcutaneous [SC] or intramuscular [IM])

• Intravenous (IV) dextrose: 12.5–25 g administered as IV, push 50%

glucose slowly over 1–2 minutes

• Manage seizure: Place the person sideways if not too agitated

Glucagon should not be repeated. In severe hypoglycaemia, it is important

to ensure that the airway is clear before administering any form of glucose.
If there is no glucagon available and the person is not able to take fluids,
honey or a sugary substance could be smeared on the buccal mucosa.

Glucagon in management of Hypoglycemia

• The dosage of glucagon given through SC or IM route is: Adult 1 mg;
children < 5 years 0.5 mg; infants 0.25 mg

• Glucagon administration increases blood glucose by 54–216 mg/dL in

60 mins

• T here are home kits available for glucagon adminis tration, e. g.

Glucagen Hypokit. 3,4,7 (Figure 2)

9
 Figure 2 : glucagen hypokit

ADA 2020 hypoglycaemia recommendations

• Individuals at risk for hypoglycaemia should be asked about

symptomatic and asymptomatic hypoglycaemia at every encounter

• Glucose (15-20 g) is preferred for the treatment of hypoglycaemia

• Patients with hypoglycaemia unawareness or recurrent episodes of

hypoglycaemia need re-evaluation of the treatment

• Glucagon should be prescribed for all individuals at an increasedrisk of

severe hypoglycaemia, and caregivers or family members should be
instructed on its administration

• Insulin-treated patients with hypoglycaemia unawareness or an episode

of severe hypoglycemia should be advised to raise their glycemic
targets

• Ongoing assessment of cognitive function is suggested.3

Prevention

When the patients consult the DE following an episode of hypoglycaemia,

the DE should ask the patients to make a note of the following:

1. When the low blood glucose occurred?

2. How they were feeling, what symptoms they had?

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3. What the blood glucose level was, if they were able to do a test?

4. What they had been doing prior to the event?

5. The type of food consumed

6. The medications taken before the event

7. Any particular event they think might have had an impact on blood
glucose levels

8. What they do to correct it?

T he ans w ers to thes e ques tions s hould be carefully as s es s ed and

accordingly preventive strategies should be devised. 4

Hypoglycaemia – Special considerations

In older people:

• Risk of injury from falls

• May be missed or mistaken for dementia

• Malnutrition may increase risk of hypoglycaemia 4

Driving safety in patients predisposed to hypoglycaemia

• Check blood glucose before driving

• If 90 mg/dL or lower, the patient should eat some carbohydrate before

driving

• Carry a source of fast-acting sugar 4

Hyperglycemia

Hyperglycaemia refers to high blood glucose levels of > 130 mg/dL during
fasting and > 180 mg/dL postprandially. Hyperglycaemia can lead to
various metabolic complications such as Diabetic Ketoacidosis (DKA) and
Hyperglycaemic Hyperosmolar Syndrome (HHS).

11
Diabetic Ketoacidosis

DKA is a metabolic complication caused as a result of hyperglycaemia.

Insulin deficiency is the main precipitating factor. DKA is commonly seen in
type 1 diabetes; however, it can occur in patients with type 2 diabetes. The
insulin deficiency stimulates more production of the counter-regulatory
hormones s uc h as gluc agon, c atec holamines , c ortis ol and grow th
hormone. There is an increase in lipase activity leading to breakdown of
adipose tissue (fats). Due to the need for energy, proteins and glycogen are
also catabolised. 4,8 (Figure 3)

Hyperglycaemia

DKA
Ketosis Acidosis

Figure 3 : Diabetes Ketoacidosis

Mechanism of DKA

A decrease in glucose uptake triggers hyperglycaemia and increased

gluconeogenesis. Glucosuria results in osmotic diuresis ultimately causing
dehydration and acidosis. Due to increased break down of fats (lipolysis)
there is excessive production of ketones. Thus, DKA is a triad of
hyperglycaemia, ketosis and acidosis.1,4 (Figure 4)

12
 Insulin deficiency

i Glucose uptake h Lipolysis

h Glycerol

Hyperglycaemia h Gluconeogenesis
h Free fatty acids

Glucosuria
h Ketogenesis
h Ketonaemia
Osmotic diuresis Electrolyte depletion h Ketonuria

Urinary water losses Dehydration

Acidosis

Figure 4 : Mechanism of DKA

Precipitating factors of DKA

DKA can be precipitated as a result of the following:

• Illness: Urinary tract infection and pneumonia are the most common
causes

• Discontinuation of or inadequate insulin

• Myocardial infarction, stroke

• Pancreatitis

• Mismanagement during sick days

• Medications such as corticosteroids, thiazides 4,9

Clinical signs and symptoms of DKA

DKA is characterised by a serum glucose level greater than 250 mg/dL, a pH

13
less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated
serum ketone level and dehydration. Table 3 given below depicts the early

Table 3: Clinical signs and symptoms of DKA

Early signs and symptoms Late signs and symptoms
• Increased thirst • Weight loss
• Increased urination • Nausea and vomiting
• Acetone breath • Abdominal pain
• Tiredness • Dehydration, warm dry skin
• Muscle cramps • Hypotension, tachycardia
• Weakness • Increased depth of breathing
• Flushed facial • Shock
appearance • Altered consciousness
• Coma

and late signs and symptoms of DKA. 4,10

4,11
Diabetic ketoacidosis – Laboratory investigations

Table 4: Laboratory values

Blood glucose 250 mg/dL

Ketones Urine: Moderate-to-large

Blood: > 3 mmol/L
+ –
Electrolytes Low/ Normal Na and Cl
+
Low/ Normal/ High K (often misleading)
–
Low HC0 3 (normal 23–31)
–
Blood pH pH • •7.3, HC03 • •15 (mild)
–
pH < 7.0, HC0 3 • • 10 (severe)

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Diabetic ketoacidosis
• Correct dehydration with IV fluids: 1L of 0.9% NaCl/ hour initially
(15–20 mL/kg/hr). Fluid is essential in the initial treatment of DKA. This
helps to reverse dehydration, which in turn reduces production of
counter-regulatory hormones. It also lowers blood glucose by improving
renal perfusion

• Lower blood glucose concentration using insulin

• Avoid hyperkalaemia or hypokalaemia: The K + levels should be

maintained optimally to avoid extremes and any complications arising
thereof

• Correct acidosis: This can be corrected using sodium bicarbonate 4

Hyperosmolar hyperglycaemic state

Relative insulin deficiency and inadequate fluid intake are the underlying
causes of HHS. It is a serious condition that mostly affects older individuals.
ls It is more commonly seen in people with type 2 diabetes. This condition
develops over weeks and is associated with severe dehydration and
hyperosmolar state. Blood glucose rises sharply due to decreased renal
perfusion and the inability to excrete excess glucose. 1,4,12

Table 5: Causes and triggers of HHS

Causes and triggers Incidence
Infection 40–60%
New-onset diabetes 33%
Acute illness 10–15%
Medicines, steroids <10%
Insulin omission 5–15%

15
 4,14
Hyperosmolar hyperglycaemic state – Signs and symptoms
• Blood sugar level of > 600 mg/dL (often 1000–2000 mg/dL)

• Excessive thirst

• Dry mouth

• Increased urination, severe dehydration

• Warm, dry skin

• Fever

• Drowsiness and confusion

• Hallucinations

• Vision loss

• Convulsions

• Usually no nausea, vomiting or abdominal pain

• Coma

Management of Hyperosmolar hyperglycaemic state

• Immediate hos pitalis ation is required to c orrec t life-threatening
abnormalities
• To correct dehydration with caution: It should be performed slowly and
steadily to avoid excess fluid crossing the blood–brain barrier and
causing cerebral oedema
• Maintain K+ levels, if hypokalaemia is present

• Lower blood glucose concentration using insulin

• Monitoring: Blood glucose, blood pressure, neurological function hourly
until stable; electrolytes 2-hourly; cardiac or central 4 venous pressure
(CVP) monitoring

16
 Table 6: Laboratory values
Blood glucose 600 mg/dL
Ketones Urine: negative – small
Blood: < 0.6 mmol/L
Osmolality >320 mOsm/kg (raised Na, blood glucose, urea)
Electrolytes Raised Na, blood glucose, urea, creatinine

Blood gases pH • •7.30

–
Normal or raised HCO3

Difference between diabetic ketoacidosis and hyperosmolar

hyperglycaemic state

4
Table 7: Distinguishing features of DKA and HHS
Factors DKA HHS
Age Younger Older
Respiration Rapid and deep Normal and shallow
Consciousness Diminished Comatose
Temperature Norma/Low May be raised
Blood glucose >240 mg/dL >600 mg/dL
Blood urea 42–70 mg/dL 60–180 mg/dL
Ketones ++ to +++ 0 to +
Types of diabetes commonly seen Type 1 Type 2

Preventive strategies
The incidence of DKA and HHS can be reduced through improved
awareness of diabetes along with early recognition of symptoms as well as
early intervention. All diabetic patients should be taught how to manage an
episode of illness and to seek help if they are unable to manage their blood

17
glucose levels. Families of elderly people with diabetes should be made
aware of the symptoms of deteriorating diabetes control (high or low) and
instructed to seek help if concerned.Educating the person and the family is
key:

• Check for ketones when blood glucose level is over 250 mg/dL

• Stay hydrated

• Monitor blood glucose levels

• When to seek medical help identify and treat underlying cause

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 5. Sick Day Management of Diabetes
If the glycaemic control is good, people with diabetes are no more likely to
become sick than the general population. However, when the control is
poor, patients have decreased immunity making them more prone to
infections.

Poor metabolic control increases the risk of infections as it:

• Decreases immunity

• Leads to persistent glycosuria and dehydration

Most of the time, the illness is mismanaged causing compli-

cations:
• A common cause of increasing hyperglycaemia and ketoacidosis

• Omission of insulin because food not consumed or vomiting

• Inadequate hydration during hyperglycaemia, polyuria and fever

• Poor glucose intake during gastroenteritis causing hypoglycaemia

• Inadequate education and written guidelines for management4,14

Hyperglycaemia and illness – General management

• Identify and treat the cause of illness

• Treat symptoms such as fever with paracetamol

• Adequate Frequent consumption of diet drinks is very important

to prevent dehydration. During illness, people should be instructed to
drink more than usual – ideally a measured amount of sugar-free drink
each hour is recommended.

• More frequent blood glucose tests

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• Check urine for ketones

• Blood ketone tests if available

Insulin management:
• Never stop insulin (fever and stress increase insulin needs)

• Continue intermediate- or long-acting insulin

• Shorter-acting insulin (soluble - or rapid-acting) should be adjusted

according to blood glucose values

• People with type 2 diabetes may need short-term insulin treatment if

the illness is severe. 4,15

When should the patient seek professional help and transferred

to the hospital? Patient should contact the physician if:
• Uncertain of diagnosis

• Persistent vomiting or diarrhea (3 episodes or more within 6 hours)

• Unwell for 2 days and not getting better

• Blood glucose remains above 270 mg/dL despite extra fluid and insulin

• Ketones >17 mg/dL despite extra fluid and insulin

Patient should be transferred to the hospital if:

• Abdominal pain worsening

• Breathing difficulty or hyperventilation

• Co-existing serious diseases

• Person looking increasingly unwell/exhausted

• Confusion/decreasing consciousness

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Sick day planning

• Early contact with healthcare professional

• Use of supplemental insulin based on blood glucose levels

• Medications available for fever

• Importance of fluid replacement when unable to eat – type and amounts

of fluid

• Monitoring blood glucose and ketones

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 6. Summary

• Hypoglycaemia is the most common preventable acute complication of

diabetes

• Hypogly caemia unawareness is commonly seen in long-standing

diabetes

• The DE can play a vital role in prevention of hypoglycaemia by

counseling and awareness creation

• DKA is common in type 1 diabetics

• HHS is common in undiagnosed type 2 diabetics and usually have

precipitating factors

• Sick day management is important to prevent acute complications of

diabetes

• DE can help the patients cope up with the illness and prevent
complications

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 References
1. Harrisons Principles of Internal Medicine.16th edition. Volume II. Chapter 323. McGraw-Hill.
USA. 2158–2161.

2. American Diabetes Association. Hypoglycaemia (Low Blood Glucose). 2015. Available at:
http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-
control/hypoglycaemia-low-blood.html. Last accessed on: 25th July 2015.
3. American Diabetes Association. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2020.
Diabetes Care. 2020;43(Suppl 1):S66-S76.

4. IDF module 2011. Module 4. Available at: http://www.idf.org/diabetes-education-modules.

5. Reno CM, Litvin M, Clark AL, et al. Defective counterregulation and hypoglycaemia
unawareness in diabetes: Mechanisms and emerging treatments. Endocrinol Metab Clin
North Am. 2013;42(1):15–38.

6. WebMD. When Your Blood Sugar Gets Too Low. 2015. Available at:
http://www.webmd.com/diabetes/diabetes-hypoglycaemia. Last accessed on: 27th July
2015.

7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian

Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management
of Diabetes in Canada. Can J Diabetes. 2013;37(1):S1-S212.

8. Westerberg DP. Diabetic ketoacidosis: Evaluation and treatment. Am Fam Physician.

2013;87(5):337–346.

9. Alourfi Z and Homsi H. Precipitating factors, outcomes, and recurrence of diabetic

ketoacidosis at a university hospital in Damascus. Avicenna J Med. 2015;5(1):11–15.

10. WebMD. Diabetic Ketoacidosis (DKA) - Topic Overview. Diabetes Health Center. 2013.
Available at: http://www.webmd.com/ diabetes/tc/diabetic-ketoacidosis-dka-topic-overview.
Last accessed on: 27th July 2015.

11. BMJ Best Practice. Diabetic Ketoacidosis. Diagnostic Criteria. 2015. Available at:
http://bestpractice.bmj.com/best-practice/ monograph/ 162/diagnosis/criteria.html. Last
accessed on: 27th July 2015.

12. American Diabetic Association. Hypersomolar hyperglycemic nonketotic syndrome. 2013.

Available at: http://www.diabetes.org/ living-with-diabetes/complications/hyperosmolar-
hyperglycaemic. html. Last accessed on: 27th July 2015

13. MayoClinic. Diabetic hyperosmolar syndrome. 2015. Available at: http://www . mayoclinic .
org/diseases - conditions/diabetic - hyperosmolar-syndrome/basics/risk-factors/con-
20026142. Last accessed on: 27th July 2015.

14. 14.WebMD. How do I manage my blood sugar when I'm sick? 2014. Available at:
http://www.webmd.com/diabetes/managing-sick-days.Last accessed on: 27th July 2015.

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ACUTE COMPLICATIONS OF DIABETES
Role plays Module 4

24
 7. Role play
Scenario 1: Mr. Lobo noticed a non-healing ulcer on his right foot. He is
worried as the wound is not healing despite of applying antiseptic
medicines. He is down with high fever and sugar levels are also running
high. Hence, he has come to visit a D.E for help.

D.E: Hi Mr. Lobo, how can I help you?

Mr. Lobo: Hi, I need your help. I am having an ulcer which is not healing for
the past few weeks. I am down with fever. Also my sugars are running high.
What should I do?

D.E: Have you applied anything on the wound?

Mr. Lobo: Yes, I have been applying antiseptic medicines for the past few
weeks still it is not healing.

D.E: Do not apply regular anti-septic creams. It is important to understand

that due to your high sugar levels, the wound is not healing. For the wound
to heal well, your blood sugar levels should be under control.

Mr. Lobo: I am also having high grade fever for the last few days

D.E: Yes, because of the infection in your wound, you are having fever.

Mr. Lobo: So what should I do now?

D.E: I advise you to visit a qualified Podiatrist who is a foot care specialist.
He will inspect your wound and advise you the treatment accordingly. He
will advise you specific lotions that are safe for you to apply. Also follow a
proper diet that will keep your sugar levels in range. It will get better with
time.

D.E looks at the hawaai chappals that he is wearing and ask him about it

Mr.Lobo: I cannot wear proper shoes to work, hence I am wearing these

hawai chappals.

25
D.E: You should not wear hawai chappals as they will cause more injury.
You should see the podiatrist immediately. He will suggest a proper
footwear and refer you to the company which makes special footwear for
diabetes.

D.E explained the foot care guidelines and handed him a leaflet of the same.

Mr.Lobo: Thank you for your guidance. I will see the podiatrist immediately

Scenario 2: A 10 year old girl is on short acting insulin and intermediate

acting insulin before breakfast and before dinner. She is going in
hypoglycaemia in school at 9.30 a.m. She takes her insulin at 7am in the
morning, eats her breakfast after 10minutes and leaves for school. Her
parentsare worriedabout her and have come to visit a D.E.

D.E.: Hi Mr. and Mrs. Grey, please have a seat. How can I help you?

Mr.Grey: Hi, my wife and I have come for our daughter who is having type 1
diabetes and is going in hypoglycaemia in her school. She is on short acting
insulin and intermediate acting insulin before breakfast and before dinner

D.E.: What time does she take insulin in the morning?

Mr.Grey: She takes insulin at 7am, has 1 cup of milk and nuts as she does
not want to eat anything heavy. She then leaves for school. We are worried
as she is experiencing hypoglycaemia in school almost every day.

D.E.: Short acting insulin starts working after 25-30minutes. So she should
eat her breakfast after 25-30minutes of taking insulin.

Short acting insulin peaks at 2 hours after administration so if she takes

insulin at 7am, it will peak around 9 am and hence she should also eat
something at that time.

Mr.Grey: We have heard that in between meals, we should give low

carbohydrate snacks. So should we give her low carbohydrate snacks at 9
a.m.

26
D.E.: Not at all. You should give her a carbohydrate containing snack,
preferably a combination of protein and carbohydrate as short acting insulin
will peak at 9am and there will be active insulin in her body.

She will go into hypoglycaemia if you give her a low carbohydrate snack at
that time as her breakfast is also not very heavy. I suggest you also meet the
doctor and review the insulin dose.

Mr.Grey: Does hypoglycaemia have long term effects on the health? What
should we do in such situations?

D.E.: Hypoglycemia affects the brain development of the child. So we need

to take precautions for it. If the sugars are <60mg%. Give her 15g
carbohydrate. It can be given in the following forms - 3 glucose tabs (5g
carbs in each), ½ cup fruit juice, 3/4th cup soft drink or 3 teaspoons of
sugar or honey. Check after 15 minutes if the sugars are still low or
symptoms persist repeat the treatment. Do not give high fat containing
sweets as they will not raise blood glucose levels immediately

Mr.Grey: Thank you so much for your help. We will now keep these things
in mind.

Scenario 3: Master Sami who is on premixed insulin 30/70 twice a day

(7am/7pm). He was been sweating at night profusely and waking up feeling
tired and weak. His parents checked the sugar levels. They found that
fasting sugar levels were high .They have come to visit a D.E. to seek
guidance for the same.

D.E.: Hi Mr. and Mrs. Sharma, please have a seat.

Mr. Sharma: My son is on premixed insulin 30/70 twice a day. His fasting
blood sugar levels are high. He is having proper dinner in the night at 8p.m
and goes to sleep by 9p.m. He is unable to sleep well and waking up feeling
tired and lethargic.

D.E.: He eats anything after dinner or at bedtime?

27
Mr. Sharma: As his fasting blood sugar levels are coming high, we are
avoiding the bedtime snack.

D.E.: I will explain. Premixed insulin is a combination of short acting and

intermediate acting insulin. Short acting insulin starts working after 25-
30minutes and peaks in 2 hours. So he should eat his dinner after 25-
30minutes of taking insulin.

Intermediate acting insulin starts its action in 1-2 hours and peaks at 6
hours after administration. So if he takes insulin at 8 pm, intermediate
acting will peak after 6 hours i.e around 2 am and cause hypoglycaemia.

Hence it is important for him to check blood glucose levels at that time. I am
assuming that it is going low at that time. I suggest if that is the case, he
should have a bedtime snack.

Mr.Sharma:Oh is it? But why his fasting sugars are running high?

D.E.: Yes, this is called as Somogyi effect. It is the body's response to low
sugar levels. Low sugar levels at mid night stimulates the body's defense
mechanisms that leads to increase in fasting sugar levels.

Mr.Sharma:How can we treat it?

D.E.: Have a bedtime snack or consult your doctor to review the insulin type
and dose

Mr.Sharma:Okay. Thank you so much. We will soon consult the doctor.

Scenario 4: A 18 year old boy Sheku has type 1 diabetes mellitus for the
past 5 years. He missed his insulininjectiondue to which he had an episode
of Diabetes Ketoacidosisand was admittedin ICU. After discharge, he was
asked to see the diabeteseducator.

D.E.: Hi Sheku, how are you?

Sheku: Hi, I am fine. I had an episode of diabetes ketoacidosis (DKA) and

was hospitalised. I have recovered now. I want to know about DKA and

28
what should I do under such conditions.

D.E.: It is a condition in which the sugar levels are above 240mg%. Due to
high sugar levels there is fat breakdown and ketones are formed. Due to
high levels of blood sugar, there is polyuria (increased urination). This leads
to dehydration and inc reas ed thirs t. S ome people als o ex perienc e
abdominal pain.

Sheku: How can I prevent this from happening?

D.E.: Do not miss you insulin dose. Continue long acting or intermediate
acting insulin. Short acting or rapid should be adjusted according to the
blood sugar levels. Take short acting or rapid acting depending on the
carbohydrate content of your meal.

Check for ketones if your sugar levels are above 240mg%. Keep urine
ketone strips or blood ketone meter handy. Take an extra shot of insulin
depending on your Insulin Sensitivity factor to bring down the sugar levels.

Sheku: They say exercise will bring down my sugar levels. Can I exercise in
such situation?

D.E.: No. You should not exercise if sugar levels are above 240mg% as
ketosis sets in. Always check sugar levels before exercise.

Sheku: What else should I do?

D.E.: Keep yourself well hydrated. If sugar is above 240mg% drink plenty of
fluids to correct dehydration and to excrete ketones from your body. Have
salty fluids like lemon water with a pinch of salt (no sugar), salty soups etc.
This is because sodium from salt helps in absorption of glucose and will
bring down the sugar levels.

If symptoms persists or get severe seek medical help immediately.

Sheku: Thank you so much for your help. I will keep these things in mind.

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Scenario 5: Mr. Paul a 46year old man who is having type 2 diabetesfor the
past 15 years. He was put on insulin 3 years ago. He is having recurrent
episodes of hypoglycaemiasince the past few days. He is taking adequate
amountof carbohydratesfor his insulindose. He has come to visit a D.E. to
seek advise for the same.

D.E.: Hi Mr.Paul, how can I help you?

Mr.Paul: Hi, I am having diabetes for the last 15 years and on insulin from 3
years. I am having recurrent episodes of hypoglycaemia since few days
despite of me having adequate amount of carbohydrates for my insulin
dose, what should I do?

D.E.: Have you done your renal profile recently?

Mr.Paul: I had done it few months ago. Should I show you the report

D.E having a look at the report observes that his serum creatinine is high. He
hasn't shown the report to the doctor

D.E.: Your renal parameters are deranged. I suggest you repeat your renal
profile and s ee your doctor immediately. He may as k you to s ee
nephrologist.

Recurrent hypoglycaemia, for reasons other than diet, exercise and

medication is an indication of renal dysfunction.

Mr Paul: Ok. I will do my renal profile and visit the doctor.

Mr. Paul did his renal profile and found that he is having microalbuminuria
and his creatinine levels have also increased. Hence diabetes educator
played an important in guiding him for treatment.

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