Diabetes Mellitus

Questions and Answers

What percentage of type 2 diabetes cases in monozygotic twins suggest strong genetic influences?

70% (correct)

90%

50%

80%

Which environmental factor is identified as the most significant cause of insulin resistance?

High stress levels

Obesity (correct)

Dietary sugar intake

Sedentary lifestyle

What type of diabetes is characterized by a genetic basis and non-insulin requiring diabetes in individuals under 25?

Gestational diabetes

Maturity-onset diabetes of the young (MODY) (correct)

Type 2 diabetes

Type 1 diabetes

Which of the following is the most common form of MODY?

MODY 3 Signup and view all the answers

What is typically the most important factor for hyperglycemia resolution in secondary diabetes cases?

Resolution of hormone excess Signup and view all the answers

What is the relationship between visceral fat and insulin resistance?

Visceral fat correlates positively with insulin resistance. Signup and view all the answers

Which drug actions are commonly associated with carbohydrate intolerance or diabetes?

Decrease insulin secretion and increase insulin resistance Signup and view all the answers

What characteristic is TRUE for patients with MODY?

They have hyperglycemia due to impaired insulin secretion. Signup and view all the answers

What fasting plasma glucose level is classified as diagnostic of diabetes?

126 mg/dL Signup and view all the answers

Which dietary requirement is necessary before conducting an Oral Glucose Tolerance Test (OGTT)?

At least 150-200 g of carbohydrate daily for 3 days Signup and view all the answers

What is the time frame for the HbA1c measurement to reflect the glycemic state?

8-12 weeks Signup and view all the answers

What is considered a normal result for the 2-hour value during an Oral Glucose Tolerance Test (OGTT)?

Less than 140 mg/dL Signup and view all the answers

Why are plasma glucose levels typically higher than whole blood glucose levels?

Whole blood includes structural components of blood cells Signup and view all the answers

A fasting plasma glucose level between which values is associated with an increased risk of diabetes?

100-125 mg/dL Signup and view all the answers

After how many hours of fasting should a blood sample be taken for a fasting plasma glucose test?

8 hours Signup and view all the answers

What is the recommended amount of glucose provided during the OGTT?

75 g Signup and view all the answers

What does a Time in Range (TIR) of 70% or more correlate with in terms of HbA1c levels?

Less than 7% Signup and view all the answers

In type 1 diabetes, uncontrolled hyperglycemia primarily affects which aspect of the lipid profile?

Slight elevation of LDL cholesterol Signup and view all the answers

What is a characteristic feature of diabetic dyslipidemia in type 2 diabetes?

High serum triglyceride levels above 300 mg/dL Signup and view all the answers

What is the role of directional arrows in glucose monitoring systems?

Show the rate and direction of glucose level changes Signup and view all the answers

Which feature is NOT typically associated with small dense LDL particles in patients with diabetes?

Lower plasma glucose concentration Signup and view all the answers

How long can a subcutaneous glucose sensor measure glucose concentrations continuously?

7-14 days Signup and view all the answers

What glucose level range defines the Time in Range (TIR) considered optimal?

70 - 180 mg/dL Signup and view all the answers

What is the primary consequence of a TIR below 70% in relation to HbA1c levels?

Higher than 7% Signup and view all the answers

What is a notable symptom of lowered plasma volume related to postural hypotension?

Serious prognostic sign Signup and view all the answers

What causes paresthesias in patients at the time of diagnosis?

Neurotoxicity due to hyperglycemia Signup and view all the answers

What characteristic odor is indicative of diabetic ketoacidosis (DKA)?

Fruity breath odor of acetone Signup and view all the answers

Which manifestation may be the initial complaint indicative of diabetes in women?

Skin infections Signup and view all the answers

In patients with hyperglycemic hyperosmolar state, what condition is typically absent?

Acidotic breathing Signup and view all the answers

What skin condition is associated with significant insulin resistance in type 2 diabetes?

Acanthosis nigricans Signup and view all the answers

What can happen to the level of consciousness due to dehydration from vomiting in ketoacidosis?

Worsen to stupor or coma Signup and view all the answers

What symptom may be present in patients with type 2 diabetes that often has an insidious onset?

Neuropathic complications Signup and view all the answers

What is the primary reason type 1 diabetes mellitus requires exogenous insulin?

To reverse the catabolic state and prevent ketosis Signup and view all the answers

Which of the following statements is true regarding the onset of type 1 diabetes mellitus?

The onset is usually rapid. Signup and view all the answers

Which factor is NOT commonly associated with type 1 diabetes mellitus?

Increased obesity rates Signup and view all the answers

What distinguishes type 2 diabetes mellitus from type 1 diabetes mellitus?

Type 2 diabetes involves insulin resistance rather than autoimmune destruction. Signup and view all the answers

For which age group is type 1 diabetes mellitus most commonly diagnosed?

Children aged 10-14 Signup and view all the answers

Which characteristic is associated with type 2 diabetes mellitus?

Sufficient residual beta cell function to avoid ketoacidosis Signup and view all the answers

What is a potential trigger for type 1 diabetes that has been noted?

Breastfeeding in infancy Signup and view all the answers

Which statement correctly describes idiopathic type 1 diabetes?

This subgroup accounts for approximately 5% of type 1 diabetes cases. Signup and view all the answers

What is a common clinical manifestation of peripheral vascular disease?

Erectile dysfunction Signup and view all the answers

What factor is NOT responsible for the development of gangrene in diabetic patients?

Tuberculosis Signup and view all the answers

What should be avoided to prevent further reduction in peripheral blood flow?

Tobacco Signup and view all the answers

Which treatment is useful as adjunctive therapy when dyslipidemia is present?

Statins Signup and view all the answers

Which symptom indicates that pedal pulses are not palpable in ischemic gangrene?

Cold and pale extremities Signup and view all the answers

What aids in the diagnosis of reduced blood flow in patients with palpable pulses?

Doppler ultrasound examination Signup and view all the answers

Which condition is frequently associated with pruritus in women with uncontrolled diabetes?

Vulvovaginitis Signup and view all the answers

Which measure is critical for patients at risk of developing diabetic foot ulcers?

Prevention of foot injury Signup and view all the answers

What is the primary benefit of SGLT2 inhibitors in diabetic patients?

They slow the progression of diabetic nephropathy. Signup and view all the answers

In patients with diabetic neuropathy, what is the most common form affecting nerves in a stocking-glove pattern?

Distal symmetric polyneuropathy. Signup and view all the answers

Which cardiovascular risk factor management is particularly crucial for diabetes patients?

Addressing obesity and treating other risk factors. Signup and view all the answers

What potential side effect is particularly of concern with RAS inhibitors in diabetic patients?

Hyperkalemia. Signup and view all the answers

Which of the following is recommended regarding ACE inhibitors and ARBs for patients with significant renal impairment?

Regular monitoring of GFR should commence prior to administration. Signup and view all the answers

What is the typical method of nerve conduction impact in distal symmetric polyneuropathy?

Delayed conduction is particularly in both motor and sensory nerves. Signup and view all the answers

How is the progression to ESRD affected in patients with albuminuria when using ACE inhibitors or ARBs?

They lower the rate of progression by reducing intraglomerular pressure. Signup and view all the answers

What is crucial for patients with diabetic nephropathy when using diuretics?

Potential reduction in diuretic dosing may be required. Signup and view all the answers

What medication is categorized as a controlled substance due to its abuse potential while being effective for treating painful diabetic neuropathy?

Pregabalin Signup and view all the answers

Which medication might lead to additional anticholinergic side effects compared to others mentioned for neuropathy treatment?

Amitriptyline Signup and view all the answers

What symptom is commonly associated with cranial nerve involvement in isolated peripheral neuropathy?

Diplopia Signup and view all the answers

Which medication is utilized primarily as a topical treatment for reducing local nerve pain?

Lidocaine patch Signup and view all the answers

What is the recommended dosage range for Gabapentin when treating painful diabetic neuropathy?

900-1800 mg daily Signup and view all the answers

What type of neuropathy is characterized by sudden onset and subsequent recovery of most function?

Isolated peripheral neuropathy Signup and view all the answers

Which of the following medications is a serotonin and norepinephrine reuptake inhibitor approved for painful diabetic neuropathy?

Duloxetine Signup and view all the answers

What common side effect is associated with Nortriptyline when used for painful diabetic neuropathy management?

Morning drowsiness Signup and view all the answers

Which complication is significantly more prevalent in patients with type 1 diabetes compared to those with type 2 diabetes?

End-stage chronic kidney disease Signup and view all the answers

In diabetic patients, which of the following is a major cause of mortality associated with type 2 diabetes?

Myocardial infarction Signup and view all the answers

What factor significantly amplifies the risk of both microvascular and macrovascular complications in diabetic patients?

Cigarette use Signup and view all the answers

Which condition is characterized by the absence of renal complications in hyperglycemic hyperosmolar state?

End-stage chronic kidney disease Signup and view all the answers

A major contributing factor to the development of orthostatic hypotension in diabetic patients is primarily due to:

Loss of peripheral nerve function Signup and view all the answers

What is a notable effect of chronic hyperglycemia on lipid profiles in diabetic patients?

Increased LDL cholesterol and decreased HDL cholesterol Signup and view all the answers

Which type of diabetes is associated with a higher prevalence of vision-threatening ocular complications?

Type 1 diabetes Signup and view all the answers

What is the primary mechanism by which diabetic cataracts develop in patients?

Accumulation of sorbitol due to hyperglycemia Signup and view all the answers

What is the primary cause of heart disease in patients with diabetes?

Coronary atherosclerosis Signup and view all the answers

Which treatment is suggested for relieving incomplete emptying of the bladder in diabetic patients?

Bethanechol administration Signup and view all the answers

Which of the following may worsen symptoms of orthostatic hypotension?

Fludrocortisone therapy Signup and view all the answers

What effect do PDE5 inhibitors have on patients using nitrates?

They are contraindicated due to hypotensive effects. Signup and view all the answers

Which of the following is a limitation of clonidine when treating diabetic diarrhea?

It can exacerbate orthostatic hypotension. Signup and view all the answers

Which method is NOT recommended for treating orthostatic hypotension?

Immediate high-intensity exercise Signup and view all the answers

How do stimulant laxatives effectively treat constipation?

By increasing peristalsis in the colon Signup and view all the answers

What underlying issue may lead to diabetic cardiomyopathy?

Microvascular complications Signup and view all the answers

What is the primary reason that bicarbonate should only be administered in acute DKA with severe acidosis?

To mitigate the risk of rebound metabolic alkalosis Signup and view all the answers

Which mechanism describes how insulin deficiency contributes to the development of DKA?

Elevated production of counter-regulatory hormones Signup and view all the answers

What consequence can result from the rapid administration of bicarbonate in a DKA patient?

Potential fatal cardiac arrhythmias due to hypokalemia Signup and view all the answers

When transitioning from intravenous insulin to subcutaneous insulin in DKA management, what is the recommended strategy?

Continue the infusion for 2 hours after the first subcutaneous dose Signup and view all the answers

What is a crucial consideration when monitoring potassium levels during the treatment of DKA?

Hyperkalemia is typical until insulin therapy is initiated Signup and view all the answers

What blood glucose level is indicative of Hyperglycemic Hyperosmolar State (HHS)?

Higher than 500 mg/dL Signup and view all the answers

What treatment protocol is typically recommended for patients with DKA after resolution?

Combination of short-acting and long-acting insulin Signup and view all the answers

Which condition is important to monitor in connection with severe acidosis during DKA management?

Cerebral edema due to electrolyte imbalances Signup and view all the answers

What is the most appropriate initial insulin infusion rate for managing a patient with hyperglycemic hyperosmolar state?

0.05 unit/kg/h Signup and view all the answers

What effect does insulin have on serum potassium levels during treatment of hyperglycemic hyperosmolar state?

Insulin drives potassium into cells, potentially leading to hypokalemia. Signup and view all the answers

What is the primary ketone measured by nitroprusside reagents in cases of diabetic ketoacidosis?

Acetoacetic acid Signup and view all the answers

How might severe dehydration in hyperglycemic hyperosmolar state complicate patient outcomes?

It can lead to increased risk of thromboembolic events. Signup and view all the answers

In what situation is a patient with diabetic ketoacidosis most likely to exhibit hypothermia?

In the absence of an infection Signup and view all the answers

What is a common recommendation for potassium management in patients with hyperglycemic hyperosmolar state?

Potassium replacement should be started early if potassium levels are not elevated. Signup and view all the answers

Which treatment protocol is recommended for patients with severe ketoacidosis?

Admission to the ICU for intensive care Signup and view all the answers

Why is the overall mortality rate of hyperglycemic hyperosmolar state coma substantially high?

It is frequently seen in older patients with major illnesses. Signup and view all the answers

What is emphasized in the long-term management strategy after stabilizing a patient with hyperglycemic hyperosmolar state?

Continuing insulin treatment initially, then trialing oral agents. Signup and view all the answers

What is a plausible reason for the elevation of serum amylase and lipase in DKA patients?

Correlating acute pancreatitis events Signup and view all the answers

How is beta-hydroxybutyric acid measured in blood during diabetic ketoacidosis assessment?

Using combined glucose and ketone meters Signup and view all the answers

What is a significant physiological change that occurs due to insulin in patients experiencing hyperglycemic hyperosmolar state?

Decreased serum osmolality as glucose levels drop. Signup and view all the answers

How should fluid replacement be strategized to prevent complications in patients with severe dehydration due to hyperglycemic hyperosmolar state?

Fluid replacement must be initiated slowly to avoid complications. Signup and view all the answers

Which of the following describes a symptom characteristic of mild DKA?

Alertness with pH levels between 7.25 and 7.30 Signup and view all the answers

What metabolic disturbance is predominantly involved in the diagnosis of diabetic ketoacidosis?

Elevated blood glucose and acidosis Signup and view all the answers

What is the significance of replenishing electrolyte losses in the treatment of DKA?

To prevent dysrhythmias and support metabolic function Signup and view all the answers

What is the primary consequence of insulin replacement therapy in the treatment of DKA?

It helps correct acidosis by decreasing fatty acid flux to the liver. Signup and view all the answers

Why might administering potassium replacement be critical during DKA treatment?

To avoid the development of hypokalemia post-acidosis correction. Signup and view all the answers

In the management of DKA, what is the maximum recommended decrease in glucose concentration per hour?

$50-70$ mg/dL/h Signup and view all the answers

What could result from over-correction of acidosis with sodium bicarbonate in DKA management?

Hypokalemia from a rapid shift of potassium into cells. Signup and view all the answers

What effect does hypokalemia have on the administration of insulin during DKA treatment?

Insulin therapy should be delayed until potassium levels are corrected. Signup and view all the answers

How does insulin treatment affect serum osmolality in DKA patients?

It decreases serum osmolality by reducing hyperglycemia. Signup and view all the answers

What is the recommended infusion rate for potassium replacement in DKA management?

10-30 mEq/h Signup and view all the answers

Which of the following best describes the process of insulin deficiency correction in DKA?

It helps by inhibiting gluconeogenesis and glycogenolysis in the liver. Signup and view all the answers

What is a key consideration when initiating fluid replacement therapy in DKA?

It can lead to cerebral edema if not done slowly. Signup and view all the answers

What serum osmolality value typically leads to lethargy and confusion in hyperglycemic patients?

310 mOsm/kg Signup and view all the answers

In the management of severe hyperglycemia, which initial fluid replacement is preferable for hyperosmolar patients?

0.45% saline Signup and view all the answers

What blood glucose range is critical for transitioning to dextrose inclusion in fluid management?

250-300 mg/dL Signup and view all the answers

In a patient presenting with severe hyperglycemia, what condition is typically absent in hyperglycemic hyperosmolar states?

Acidosis Signup and view all the answers

What volume of fluid replacement is typically required in the first 8-10 hours for severe dehydration?

4-6 L Signup and view all the answers

What physiological condition can cause a further reduction in insulin requirement for non-ketotic patients?

Corrected hypovolemia Signup and view all the answers

What complication is associated with serum osmolality exceeding 330 mOsm/kg in hyperglycemic patients?

Convulsions and coma Signup and view all the answers

Which fluid therapy approach is advised when hypotension and oliguria are present?

Begin with 0.9% saline Signup and view all the answers

Study Notes

Diabetes Mellitus Overview

Hyperglycemia is defined as elevated glucose levels in the blood, a key characteristic of diabetes mellitus.
Diagnostic criteria include fasting plasma glucose, oral glucose tolerance tests, and glycated hemoglobin levels.

Classification of Diabetes Mellitus

Type 1 Diabetes Mellitus:
- Autoimmune condition leading to destruction of pancreatic beta cells.
- Most prevalent in children and young adults, typically diagnosed between ages 10-14.
- Ketosis is common in untreated cases; requires exogenous insulin.
- Genetic factors increase risk; higher incidence in Scandinavian countries.
- Breastfeeding in infancy offers some protective benefit.
- Rapid onset, with diabetic ketoacidosis often serving as initial presentation.
- Approximately 5% may be classified as idiopathic type 1 diabetes (type 1B), without autoimmunity evidence.
Type 2 Diabetes Mellitus:
- Caused by non-immune pancreatic beta cell dysfunction and insulin resistance.
- Historically more common in adults but increasingly seen in children and adolescents.
- Genetic predisposition indicated by a 70% concordance rate in monozygotic twins.
- Over 140 risk variants identified through genome-wide association studies.
- Obesity, particularly visceral fat, is a significant environmental factor leading to insulin resistance.
Maturity-Onset Diabetes of the Young (MODY):
- Monogenic diabetes that does not require insulin, with autosomal dominant inheritance.
- Onset is typically before age 25; characterized by non-obesity and impaired insulin secretion.
- MODY 3 is the most common form, often responsive to sulfonylureas but can progress to require insulin.
Secondary Diabetes:
- Results from endocrine tumors or drugs affecting insulin sensitivity or secretion.
- Excess hormones can impair glucose metabolism; symptoms resolve once hormone levels normalize.

Symptoms & Clinical Signs

Type 2 Diabetes Symptoms:
- Skin infections, generalized pruritus, and chronic candidal infections, particularly in women.
- Acanthosis nigricans is indicative of insulin resistance.
Diagnostic Tests:
- Fasting plasma glucose ≥126 mg/dL confirms diabetes; values 100-125 mg/dL indicate risk.
- Oral glucose tolerance test (OGTT): 75g of glucose consumed; values define diabetes through a 0 and 120-minute intervals.
- Hemoglobin A1c reflects average glucose levels over previous 8-12 weeks; normal is 4-6%.
- Diabetic dyslipidemia in type 2 characterized by high triglycerides, low HDL, and small dense LDL particles.

Other Important Considerations

Neuropathy may present as paresthesias related to hyperglycemia.
Level of consciousness can vary with hydration status and ketoacidosis, with risk of coma.
Hyperglycemic hyperosmolar state occurs with serum osmolality exceeding 320-330 mOsm/L, leading to severe dehydration.
Regular monitoring, lifestyle changes, and medication adherence are essential for management and prevention of complications.

Peripheral Vascular Disease

Characterized by diffuse blood flow with localized enhancement at aorta bifurcation and large vessels.
Clinical manifestations include ischemia in lower extremities and erectile dysfunction.
Diabetic patients experience gangrene of the feet at a 30-fold higher incidence than non-diabetics.
Causes of gangrene aside from peripheral vascular disease include peripheral neuropathy and secondary infections.
Ischemic gangrene presents with non-palpable pedal pulses; Doppler ultrasound can show reduced blood flow despite palpable pulses.
Essential prevention strategies include avoiding foot injuries and controlling tobacco use and hypertension.
Beta-blockers are relatively contraindicated due to their negative impact on peripheral circulation.
Statins are beneficial as adjunctive therapy upon detection of early ischemic signs and dyslipidemia.
Urgent medical care is advised for any diabetic foot ulcer.
Surgical options like angioplasty or bypass may improve peripheral blood flow in select patients.

Skin and Mucous Membrane Complications

Bacterial skin infections are common in poorly controlled diabetic patients.
Candidal infections can cause erythema and edema in intertriginous areas and vulvovaginitis in women, especially with glucosuria.
Antifungal creams like miconazole or clotrimazole relieve vulvovaginitis but recurrence is likely unless glucosuria is managed.
Patients should inspect feet daily for any injuries, as sensory deficits can exacerbate issues.
Severe "burning" pain may be physically and emotionally disabling; nortriptyline and desipramine can offer pain relief.
Gabapentin and pregabalin are effective for diabetic neuropathy pain, but pregabalin is classified as a controlled substance.

Isolated Peripheral Neuropathy

Involves single nerve (mono-neuropathy) or multiple nerves (mono-neuropathy multiplex) and typically has a sudden onset.
Commonly affects cranial or femoral nerves, leading to motor abnormalities like diplopia and weaknesses in extraocular movements.

Chronic Complications of Diabetes Mellitus

Chronic complications can be classified into macrovascular, microvascular, and others.
Long-duration diabetes correlates with serious complications like chronic kidney disease, blindness, and amputations.
Up to 40% of type 1 diabetes patients develop end-stage chronic kidney disease vs. less than 20% in type 2.
Diabetic retinopathy is prevalent in both types, higher in type 1 patients (25% after 15 years).
Cigarette smoking significantly increases the risk of both microvascular and macrovascular complications.

Ocular Complications

Diabetic cataracts develop prematurely and are related to chronic hyperglycemia duration and severity.
ACE inhibitors or ARBs can slow progression to end-stage renal disease in patients with albuminuria but require monitoring for hyperkalemia.

Diabetic Neuropathy

Affects up to 50% of diabetic patients; peripheral neuropathy is the most common form.
Distal symmetric polyneuropathy shows loss of function in a "stocking-glove" pattern, with initial sensory loss occurring bilaterally.

Genitourinary System Complications

Incomplete bladder emptying may occur; page treatment options include bethanechol and catheter decompression.
Erectile dysfunction can stem from neurologic, psychological, or vascular issues.
PDE5 inhibitors (sildenafil, vardenafil, tadalafil) are effective for erectile dysfunction but contraindicated with nitrates.

Orthostatic Hypotension

Symptoms can be alleviated with lifestyle adjustments like wearing fitted stockings and rising slowly.
Fludrocortisone and alpha-agonist midodrine may be appropriate for treatment when lifestyle changes are insufficient.

Cardiovascular Complications

Microvascular issues can lead to diabetic cardiomyopathy.
The majority of heart disease in diabetes is attributed to coronary atherosclerosis, a macrovascular complication.

Tissue Anoxia and Acidosis

Tissue anoxia may occur due to reduced oxygen dissociation from hemoglobin when acidosis is reversed, represented by a leftward shift in the oxygen dissociation curve.
Rapidly correcting cerebral acidosis can lead to lowered cerebrospinal fluid pH, complicating patient status.

Bicarbonate Administration in DKA

Bicarbonate is recommended only for severe acidosis (arterial pH ≤ 7.0), accompanied by careful monitoring.
Sodium bicarbonate (1 ampule = 44 mEq/50 mL) is to be added to 1 L of 0.45% saline with 20 mEq KCl, infused over 2 hours.
Repeated infusions can occur until pH reaches 7.1, avoiding administration if pH is 7.1 or higher to prevent rebound metabolic alkalosis.

Risks of Metabolic Alkalosis

Alkalosis shifts potassium from serum into cells, which may result in fatal cardiac arrhythmias.

Treatment of Associated Infections

Antibiotics are necessary, especially for severe conditions like cholecystitis and pyelonephritis.

Transition to Subcutaneous Insulin

After DKA is controlled and the patient is alert and able to eat, initiate subcutaneous insulin therapy.
Calculate the initial insulin doses based on the amount used in the last 8 hours; split the total daily dose equally between long-acting and short-acting insulin.

Hyperglycemic Hyperosmolar State (HHS) Essentials

Diagnosis requires hyperglycemia > 600 mg/dL. Ketoacidemia results from insulin deficiency.
Insulin lack leads to elevated growth hormone, catecholamines, and glucagon, enhancing lipolysis and hepatic ketogenesis.
Nitroprusside tests detect acetoacetic acid but fail to identify beta hydroxybutyric acid, a major contributor to acidosis.
Bedside dipstick tests can produce false negatives if beta-hydroxybutyrate predominates.

Diagnostic Indicators

Nonspecific elevations in serum amylase and lipase occur in 16-25% of DKA cases; imaging may be necessary for suspected pancreatitis.
Leukocytosis can reach 25,000/mcl, with fever indicating potential infection—usually hypothermic in uninfected DKA.

Treatment Approaches for DKA

Classify DKA severity based on pH levels:
- Mild (pH 7.25-7.30)
- Moderate (pH 7.0-7.24)
- Severe (pH < 7.0) requiring ICU admission.
Goals of treatment: restore plasma volume and tissue perfusion, normalize blood glucose and osmolality, correct acidosis, replenish electrolytes, and address triggers of DKA.

Insulin Replacement Therapy

Administer regular insulin via IV after fluid replacement, starting with a loading dose of 0.1 unit/kg followed by continuous infusion at 0.1 unit/kg/h.
Insulin therapy reduces acidosis and hyperosmolality by promoting glucose utilization and inhibiting hepatic glucose production.

Potassium Management

DKA leads to substantial potassium loss; serum levels may appear normal or elevated because of acid-base imbalances.
As acidosis corrects, potassium shifts intracellularly, possibly leading to hypokalemia; replacement is critical, typically with potassium chloride at 10-30 mEq/h.
Delay insulin therapy if serum potassium < 3.5 mEq/L until levels are corrected.

Sodium Bicarbonate Use

Use of sodium bicarbonate in DKA treatment is controversial due to potential rapid shifts in potassium and risks of hypokalemia from overcorrection.

Prognosis and Complications

Severe dehydration in HHS can lead to myocardial infarction, stroke, pulmonary embolism, and mesenteric vein thrombosis.
Fluid replacement is critical in preventing these severe outcomes, with low-dose heparin considered for prophylaxis.
Mortality from HHS exceeds that of DKA, often due to older age, underlying illnesses, and delays in recognition and treatment.

Long-term Management

Post-stabilization, review long-term diabetes management; insulin therapy may be needed temporarily until endogenous insulin production improves.
Patient education regarding glucose monitoring and hydration is essential.
Symptoms like lethargy and confusion appear as serum osmolality exceeds 310 mOsm/kg, with severe cases risking convulsions and coma at > 330 mOsm/kg.

Laboratory Findings in HHS

Severe hyperglycemia typically ranges from 800 mg/dL to 2400 mg/dL.
As dehydration progresses, sodium may exceed 140 mEq/L, leading to elevated serum osmolality (330-440 mOsm/kg).
Ketosis and acidosis are generally absent or mild, with prerenal azotemia indicated by elevated serum urea.

Fluid Replacement Protocol

Fluid replacement is crucial; deficits can reach 6-10 L.
Initiate therapy based on hypotension with 0.9% saline; otherwise, 0.45% saline is preferable for hyperosmolar patients.
Administer 4-6 L of fluids within the first 8-10 hours, aiming to restore urinary output above 50 mL/h.
Incorporate 5% dextrose once blood glucose reaches 250 mg/dL, adjusting the infusion rate to maintain levels between 250-300 mg/dL to mitigate cerebral edema.

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Description

Explore the fundamental aspects of diabetes mellitus, including its definition, diagnostic criteria, and classification into Type 1 and Type 2 diabetes. This quiz covers essential information about the autoimmune nature of Type 1 diabetes, risk factors, and the pathophysiology of Type 2 diabetes. Test your knowledge on these critical health topics.