DIABETES

Section B2 - Group 5
Umbao, Lyndon Marvin P.
Uson, Adrian S.
Valderrama, Bea Aira B.
Valencia, Gene Paolo S.
Valenzuela Airam Ydet D.R.
Vanguardia, Nino Jerome Joaquin
Ventura, Paula Marie S.
Verano, Sarah Sharmaine U.
Vergara, Adrian Joseph P.
Villamarin, Ara Kaye B.
Villamartin, John Paul V.
Villamor, Josef Christian V.
 • 65 yo, male, Catholic,
married, residing in
Valenzuela area

CHIEF COMPLAINT: VOMITING

General Data:
 1 week PTC
2 weeks PTC • recurrence of fever at
• productive cough (whitish sputum) 38-39C,
• Fever • with yellowish green
• self-medication (amoxicillin 500mg phlegm
1 cap TID for 5days), • anorexia
• resolution of fever
• epigastric pain, nausea
• persistent cough

HISTORY OF PRESENT ILLNESS:

 1 day PTC
• persistence of above symptoms
• 5 bouts of vomiting &
• generalized weakness.

• Pt was brought to the ER

HISTORY OF PRESENT ILLNESS:

 Past Medical History
• Type 2 DM diagnosed 2010, maintained
(Metformin 500mg BID and gliclazide 80 mg
OD) w/ questionable compliance
• no regular check-ups with endocrinologist
• hypertension 2010 (amlodipine 5 mg OD,
telmisartan 40 mg OD)
• cholecystectomy 1998

Salient Features:
 Physical Examination:
• Estimated weight – 85 kg
• Estimated height – 5’6 (167.74 cm)
• BMI – 30.5
• BP – 110/60 CR – 120/min RR – 28/min
• Temperature – 38C
• CBG – 450 mg/dL

Salient Features:
 Family History
• Mother has DM type 2
• 2 siblings have DM type 2

Salient Features:
 Personal and Social History
• previous smoker 10 pack years,
• occasional alcoholic drinker

Salient Features:
 Review of Systems
• No nasal discharge
• No headache
• No chest pain
• No diarrhea
• No bleeding tendencies

Salient Features:
 Physical Examination:
• Pink palpebral conjunctivae, anicteric Sclerae
• Dry oral mucosa, poor skin turgor
• Tachypneic with prolonged expiratory phase,
• Equal vocal fremitus, fine crackles both lung field R>L,
• Occassional wheezes
• (+) Acetone Breath

Salient Features:
 Physical Examination:
• Cardiovascular System – unremarkable
• Abdomen - flabby, hypoactive bowel sounds, direct epigastric
tenderness, localized, no guarding, no palpable masses
• Extremities : no bipedal edema, dry scaly skin with
hyperpigmented patches, pulse fair and equal
• Neurologic Exam: conscious, coherent but drowsy and easily
dozes back to sleep after interview
• Cranial nerves intact, MMT 4/5 on all extremities

Salient Features:
DIABETIC KETOACIDOSIS

DIAGNOSIS:
BASIS:
Diabetic Ketoacidosis  Tachypneic (28/min)
 (+) Kussmaul respiration –
 Anorexia
characterized by prolong expiration
 Nausea and Vomiting
 Epigastric pain – resembles
pancreatitis
 CBG: 450 mg/dL
 Diagnosed with DM2
 Dry oral mucosa & poor skin turgor
 (+) DM family history
with dry scaly skin
 Hypotensive (110/60)
 Lethargic
 Tachycardic (120/min)
 (+) Acetone Breath – classic sign of
DKA
Laboratory Exams
 Urine Dipstick Testing Plasma Glucose Study
• For patients with DKA, the urine
• The blood sugar level for
dipstick test is highly positive for
glucose and ketones. Rarely, urine is
patients with DKA usually
negative for ketones, due to the fact exceeds 250 mg/dL. The
that most available laboratory tests clinician can perform a
can detect only acetoacetate, while fingerstick blood glucose test
the predominant ketone in severe while waiting for the plasma
untreated DKA is beta- glucose level.
hydroxybutyrate.

• When the clinical condition improves

Laboratory
with treatment, the urine test result
becomes positive due to the returning
predominance of acetoacetate.

Exams
 Ketones • According to the 2011 Joint
• In patients with DKA, serum ketones British Diabetes Societies
are present. Blood beta- (JBDS) guideline for the
hydroxybutyrate levels measured by a management of diabetic
reagent strip (Ketostix, N-Multistix, ketoacidosis, capillary blood
and Labstix) and serum ketone levels ketones should be measured in
assessed by the nitroprusside order to monitor the response
reaction are equally effective in to DKA treatment. The method
diagnosing DKA in uncomplicated of choice is bedside
cases. measurement of blood ketones
using a ketone meter. In the
absence of blood ketone
measurement, venous pH and

Laboratory bicarbonate should be used

together with bedside blood

Exams
glucose monitoring to evaluate
treatment response.
 Arterial Blood Gas • When monitoring the response to
treatment, the 2011 JBDS guideline
• In patients with recommends the use of venous blood
DKA, arterial blood rather than arterial blood in blood gas
gases (ABGs) frequently analyzers, except where respiratory
show typical problems preclude using arterial blood.
manifestations of
metabolic acidosis, • Venous pH may be used for repeat pH
low bicarbonate, and measurements. Brandenburg and Dire found that
low pH (less than 7.3). pH on venous blood gas in patients with DKA was
0.03 lower than pH on ABG. Because this
difference is relatively reliable and not of clinical
significance, there is almost no reason to perform
Laboratory the more painful ABG. End tidal CO2 has been
reported as a way to assess acidosis as well.

Exams
 Serum Electrolyte
Serum potassium levels initially are
high or within the reference range in
patients with DKA. This is due to the
extracellular shift of potassium in
exchange of hydrogen, which is
accumulated in acidosis, in spite of
severely depleted total body potassium.
This needs to be checked frequently, as
values drop very rapidly with treatment.
An ECG may be used to assess the
cardiac effects of extremes in potassium
levels.
Laboratory
Exams
• The serum sodium level usually is low in
affected patients. The osmotic effect of
hyperglycemia moves extravascular
water to the intravascular space. For
each 100 mg/dL of glucose over 100
mg/dL, the serum sodium level is lowered
by approximately 1.6 mEq/L. When
glucose levels fall, the serum sodium
level rises by a corresponding amount.
• Additionally, serum chloride levels and
phosphorus levels always are low in
these patients.
 Bicarbonate Anion Gap
• Use bicarbonate levels in • In patients with diabetic
conjunction with the anion gap ketoacidosis, the anion gap is
to assess the degree of elevated ([Na + K] - [Cl + HCO3]
acidosis that is present. greater than 10 mEq/L in mild
cases and greater than 12
mEq/L in moderate and severe
cases).

Renal Function Test

• BUN frequently is increased in patients
with diabetic ketoacidosis.
Laboratory
Exams
 Amylase
Phosphate, Calcium, and Magnesium
• Hyperamylasemia may be seen
• If the patient is at risk
in patients with diabetic
for hypophosphatemia  (eg, poor
ketoacidosis, even in the
nutritional status, chronic alcoholism),
absence of pancreatitis.
then the serum phosphorous level
should be determined. Chest radiograph
• Chest radiography should
Osmolarity be used to rule out
• Plasma osmolarity usually is increased pulmonary infection such as
(greater than 290 mOsm/L) in patients pneumonia.
with diabetic ketoacidosis. If plasma
osmolarity cannot be measured directly, CBC
• CBC shows an increased white blood

Laboratory
it may be calculated with the following
formula: plasma osmolarity = 2 (Na + K)
+ BUN/3 + glucose/18. Urine osmolarity
also is increased in affected patients.
cell (WBC) count in patients with
diabetic ketoacidosis. High WBC counts
(greater than 15 X 109/L) or marked left
shift may suggest underlying infection.
Management of
Diabetic Ketoacidosis
 • It is very important to hydrate the patient
• Correct the hyperglycemia using insulin
• Correct electrolyte imbalances
 To prevent arrhythmia,
Treatment hyper/hyponatremia,
hyper/hypokalemia
• Identify and treat the comorbid illnesses
• Frequent patient monitoring
 • Confirm the diagnosis (increase
glucose, positive serum
ketones, metabolic acidosis)
• Assess serum electrolytes,
Management of acid-base status, renal
function(creatinine, urine
Diabetic Ketoacidosis output)
Four major arms
to increase the BP --- isotonic saline, plain
NSS, plain LR.
 • Replace fluids using 850ml-1,700ml
of 0.9% saline over the 1st 1-3 hours
Management of (10-20ml/kg or 10-20ml/85kg);
subsequently 0.45% saline at 250-
Diabetic 500ml/h; changed to 5% glucose and
0.45% saline at 150-250 ml/h when
ketoacidosis plasma glucose reaches 250 mg/dl
(13.9 mmol/L)
 • Administer short-acting regular insulin: IV 8.5
units (0.1/kg or 0.1/85kg), then 8.5 units per
hour continuous IV infusion (0.1/kg per hour or
0.1/85kg ); increase 2-3 folds if no response by
2-4 hours. If the initial serum potassium <3.3
mmol/L(3.3 meq/L), do not administer insulin
Management of until the potassium is corrected
• Measure capillary glucose every 1-2 hours;

Diabetic ketoacidosis
measure electrolytes (especially
bicarbonate, phosphate ) and anion gap every
k+,

4hours in the 1st 24hours

• Monitor blood pressure, pulse, respirations,
mental status, fluid intake and output every 1-4
hours
 • Replace K+: 10meq/h when plasma
(or 20-30meq/L of infusion fluid), ECG
normal, urine flow and normal creatinine
documented;

• administer 40-80 meq/h when plasma k+

<3.5 meq/L or if bicarbonate is given. If
Management of Diabeticinitial potassium is >5.2 mmol/L
(5.2meq/L), do not supplement k+ until
ketoacidosis potassium is corrected
• Bicarbonate should be given regardless if
the ph is <7 or >7 because our patients
has a concomitant respiratory infection
 • Continue the mentioned management until
the patient is stable, glucose goal is 8.3-11.1
mmol/L (150-200mg/dl) , acidosis is resolved,
Insulin infusion may be decreased to 1.7-8.5
units per hour (0.02-0.1units/kg or 0.02-0.1
units/85kg per hour)
Management of
Diabetic ketoacidosis • Administer long acting insulin as soon as the
patient is eating. Allow for a 2-4 hour overlap
in insulin infusion and SC long-acting insulin
injection
 • A β-lactam [e.g.,
• A respiratory fluoroquinolone
ceftriaxone (1–2 g IV qd),
[e.g., moxifloxacin (400 mg PO
ampicillin (1–2 g IV q4–6h),
or IV qd) or levofloxacin (750
cefotaxime (1–2 g IV q8h),
mg PO or IV qd)]
ertapenem (1 g IV qd)] plus
a macrolide [e.g., oral
clarithromycin or IV
azithromycin (1 g once,
then 500 mg qd)]

Empirical Antibiotic Treatment of Community-

Acquired Pneumonia
• Organisms that cause pulmonary infections similar to those in non-
diabetics

 Gram (-) organisms,

 Staphylococcus aureus,
 Mycobacterium tuberculosis are more
frequent pathogens

PULMONARY INFECTIONS AS
COMPLICATION OF DM
 PERTINENT FINDINGS IN PATIENT:
HISTORY PE
 Persistent productive  Tachypnea w/ prolonged
cough expiratory phase
 Yellowish-green phlegm  Fine crackles both lung
 Anorexia fields
 Nausea  Occasional wheezes
 Generalized weakness

PULMONARY INFECTIONS AS
COMPLICATION OF DM
 DIAGNOSTICS
• Chest radiograph • Microscopy • Culture
 Pneumatoceles  Gram stain (S.
(Pneumonia); aureus
Cavitation (TB) Pneumonia);
Acid Fast Bacilli
stain
(Mycobacterium
tuberculosis)

PULMONARY INFECTIONS AS
COMPLICATION OF DM
MANAGEMENT: PNEUMONIA

PULMONARY INFECTIONS AS
COMPLICATION OF DM
MANAGEMENT: TB

PULMONARY INFECTIONS AS
COMPLICATION OF DM
MANAGEMENT: TB
• Many anti-TB drugs are metabolized in the liver
• Rifampin induces liver enzymes that inactivate
sulfonylureas metabolized in the liver
• Sulfonylureas may become less effective and should
preferably be avoided

PULMONARY INFECTIONS AS
COMPLICATION OF DM
• Optimal monitoring of glycemic control involves plasma glucose
measurements by the patient and an assessment of long-term
control by the providers on the diabetes management team
(measurement of hemoglobin A1c [HbA1c] and review of the
patient’s SMBG).

• These measurements are complementary: the patient’s

measurements provide a picture of short-term glycemic control,
whereas the HbA1c reflects average glycemic control over the
previous 2–3 months.

Parameters that will determine that the patient

is pulled out of hyperglycemic control
• The standard of care in diabetes management and allows the patient to
monitor his or her blood glucose at any time.

• A small drop of blood and an easily detectable enzymatic reaction

allow measurement of the capillary plasma glucose. Many glucose
monitors can rapidly and accurately measure glucose

Self-Monitoring of Blood Glucose

(SMBG)
• Standard method for assessing long-term glycemic control.

• When plasma glucose is consistently elevated, there is an increase in non-

enzymatic glycation of hemoglobin.

• Measurement of HbA1c at the “point of care” allows for more rapid feedback and
may therefore assist in adjustment of therapy.

• HbA1c should be measured in all individuals with DM during their initia

evaluation and as part of their comprehensive diabetes care.

Measurement of glycated
hemoglobin (HbA1c)
6. When can patient started
on oral food intake ?
 Oral food intake can be started once the
patient is metabolically stable and DKA is
resolved.
Criteria for resolution:

• Plasma Glucose < 200mg/dL

• Serum Bicarbonate level ≥ 15mEq/L
• Venous Ph > 7.3
• Calculated anion gap ≤ 12mEq/L
When the patient is able to tolerate oral intake
and DKA resolved
FLUIDS • Continue D5-containing IVF while on NPO
• May shift fluid back to plain NSSS once feeding

INSULIN • Start subcutaneous insulin 24 units/day (0.5-0.8

units/kg/dat for an insulin naïve patient) with 50% as
prandial insulin; adjust accordingly thereafter
• Continue insulin drip for 1-2 hrs after eating starting the
SC dose

POTASSIUM • Continue monitoring while on insulin drip and correct

accordingly
BICARBONATE • May decrease monitoring to q12 hrs

MONITORING • Decrease monitoring of RBS, BUN, Na, K, Cl;

VBG to every 24hrs
• Decrease monitoring of BP, pulse, respiration,
mental status and fluid intake and output to
every 4 hrs

OTHERS • May transfer to regular room

• May start gradual progression of diabetic diet.
• Work up for type 1 DM: C-peptide, GAD,
antibodies, zinc transporter- 8 antibodies.
  Selected patients with mild DKA who are alert
and taking fluids orally may be treated under
observation and sent home without
admission. The ADA admission guidelines are
a plasma glucose concentration greater than
DISCHARGE 250 mg per dL (13.9 mmol per L) with an
arterial pH level below 7.30, a serum

PLANS
bicarbonate level of less than 15 mEq per L,
and a moderate or greater level of ketones in
the serum or urine. Patients with severe DKA
should be admitted to the intensive care unit.
 The doctor will give you a list of your
medicines when you leave the hospital
 Follow your provider's recommendations for
follow-up visits and routine tests.
 Plasma glucose
D  Electrolytes with calculated anion gap and effective osmolality

P
Phosphorous
I Blood urea nitrogen and creatinine
S Beta-hydroxybutyrate or serum ketones if not available

C
Complete urinalysis with urine ketones by dipstick
Arterial blood gas or venous pH level if not available
Complete blood count with differential
L
H Electrocardiography
As indicated A
A Bacterial cultures of urine, blood, throat, or other sites of suspected infection

R
Chest radiography if pneumonia or cardiopulmonary disease is suspected
Magnesium if patient has signs of hypomagnesemia such as cardiac
N
G arrhythmias, is alcoholic, or is taking diuretics
A1C level may help determine whether this is an acute episode in a patient S
E with well-controlled, undiagnosed, or poorly controlled diabetes.
A • Take your insulin and other diabetes medicines on time and in the right dose.
• Test your blood sugar before meals and at bedtime or as often as your doctor
advises.
D • Teach others at work and at home how to check your blood sugar
• Wear or carry medical identification at all times. This is very important in case

V you are too sick or injured to speak for yourself

• Talk to your doctor about when you can start to exercise again.

I
• Eat regular meals that spread your calories and carbohydrate throughout the
day. This will help keep your blood sugar steady.
• When you are sick:Take your insulin and diabetes medicines

C • Drink extra fluids to prevent dehydration

• Try to eat as you normally do, with a focus on healthy food choices.

E • Check your blood sugar at least every 3 to 4 hours. Check it more often if it's
rising fast.
• Check your temperature and pulse often
S • If you take insulin, check your urine or blood for ketones, especially when you
have high blood sugar
A • If you know your blood sugar is high, treat it before it gets worse.

D
• If you missed your usual dose of insulin or other diabetes medicine, take the
missed dose or take the amount your doctor told you to take if this happens.
• If you and your doctor decide on a dose of extra-fast-acting insulin, give

V yourself the right dose. If you take insulin and your doctor has not told you
how much fast-acting insulin to take based on your blood sugar level, call
your doctor or nurse call line.
I • Drink extra water or sugar-free drinks to prevent dehydration.
• Wait 30 minutes after you take extra insulin or missed medicines. Then check

C your blood sugar again.

• If symptoms of high blood sugar get worse or your blood sugar level keeps
rising, call your doctor or nurse call line
E
S