DM

SMR MOUSA
LECTURER IN CRITICAL CARE ILLNESS
• DEF
• TYPES
• PATHOPHYSIOLOGY
• Clinical consequences
Definition :
• metabolic disorder characterized by
chronic hyperglycemia
disturbances of carbohydrate, fat, and protein metabolism
resulting from defects in insulin secretion, insulin action, or
both
Type 1
• Type 1 diabetes can occur at any age, but usually develops in children
or adults <30 years
• This occurs as a result of lack of insulin production by the pancreatic
B cells.
• It requires treatment with insulin and dietary management.
Type 2
• Type 2 diabetes is usually diagnosed in older adults
• It is associated with a lack of insulin function as a result of insulin
resistance with or without insufficient production
• strongly associated with overweight and obesity.
• Dietary management is required, with or without oral hypoglycaemic
agents or insulin.
Gestational diabetes
• Gestational diabetes is hyperglycemia diagnosed during pregnancy
that had not been previously diagnosed.
• Advice about diet, exercise and body weight is required, and some
patients may also need insulin
pathophysiology
Diagnosis
Impaired glucose tolerance
• FASTING :100: 126 mg / dl
• pp :140: 199 mg / dl
Clinical consequences
• Diabetes is associated with:
increase risk of serious chronic ill health
disability
premature mortality.
Long-term complications:
• macrovascular disease :cardiovascular disease ,,risk of stroke
• microvascular disease :
retinopathy
nephropathy
neuropathy.
People with diabetes also have a greater risk of suffering from
infections .
Many of these complications can be minimized or avoided by earlier
diagnosis and more effective treatment
Key priorities for management (Adults)
• Multidisciplinary team approach
• Education
• Blood glucose control
• Arterial risk-factor control
• Management of late complications
Key priorities for management (children and
young adult)
• Education
• Monitoring glycaemic control
• Screening for complications and associated conditions
• Psychosocial support
Education is a central part of management of
type 1 diabetes
• Aim to enable people to make optimal choices about foods they consume
• Facilitate insulin dose changes when taking different quantities of those foods
• Review education needs annually
• Ongoing education with access to information and opportunities for
discussion at clinic visits
• Advise on effects of nutritional changes on glycaemic control
• Give support to help optimize weight
• Discuss timing and composition of snacks and problems associated with
fasting and feasting
• Multiple daily injections: adjust insulin to carbohydrate intake.
Goals of dietary management
• reduction of risk for microvascular disease by achieving near normal
glycaemia without undue risk of hypoglycaemia
• reduction of risk of macrovascular disease including management of
body weight, dyslipidaemia, and hypertension.
• To optimize outcomes in microvascular disease
Principles of dietary management
• People with diabetes do not need to follow a ‘special diet’ or comply
with narrow restrictions
• The optimum healthy choice of food for people with diabetes is the
same as for the general population ideally should be:
low in fat, sugar, and salt
include plenty of fruit and vegetables
base meals on starchy foods such as bread, potatoes, and rice
Ten steps to healthy eating in diabetes
• Eat three meals a day and avoid skipping meals. Spread breakfast,
lunch and evening meal across the day.
• Include starchy carbohydrate foods The better choices include
wholegrain and granary bread, oats, new potatoes and yam.
• Reduce intake of fat, especially saturated fat. Eat less butter,
margarine, cheese, and fatty meat and instead choose low fat dairy
foods, lean meat and fi sh. Replace fried foods with grilled, steamed,
or oven baked items. Use small quantities of mono-unsaturated oil,
e.g. olive oil
• Eat more fruit and vegetables: aim for at least fi ve portions per day.
 Continue …………..
• Include more beans and pulses, for example kidney beans
• Oily fi sh: aim for at least two portions per week. These could include
mackerel, sardines, salmon, and pilchards.
• Reduce sugar and sugary foods. Following a strict sugar-free diet is not
necessary — sugar can be used as an ingredient in foods, e.g. in
wholegrain breakfast cereals. Sugary drinks can be replaced
• Cut down on salt by limiting the amount of processed foods consumed as
well as added table salt. Herbs and spices can be used as an alternative.
• Drink alcohol in moderation which is a maximum of two units per day for
women and three units per day for men
• Diabetic food products offer no health benefits, often contain high levels
of energy, can have a laxative effect and are expensive.
 Continue …………..
The potential benefits from decrease intake of high GI foods and
replacing them with increase low GI food ….Greater satiety
• Helping to maintain a more even blood glucose level, thus d both
hypoglycaemia and high blood sugar levels sometimes observed after
meals.
• Improvements in lipid profile which is associated with d cardiac risk.
Types of insulin ………….
Dietary management of adults treated with
insulin analogues
• Meals
• Consider post-prandial injection of rapid-acting IA if person eats meal
with unpredictable amount of CHO, e.g. buffet
• Consider postprandial injection of rapid-acting IA if person eats meal that
may l d post-prandial blood glucose, i.e. low GI or high fat meal
• If meal is low GI or high fat, consider dividing bolus of rapid-acting IA to d
risk of delayed hypoglycaemia.
• Dose of insulin should be adjusted primarily on the CHO content of the
meal.
• If blood sugar i by > 2–3 mmol/l after meal, review insulin to CHO ratio
snakes
• For patients using glargine, supper snack is usually unnecessary.
• Use blood glucose and preference to determine if supper snack is
needed after a 1–2-week settling period.
• • If large amounts of alcohol are consumed, a supper snack may be
needed to prevent hypoglycaemia even if glargine is used.
• • People treated with rapid-acting IA and glargine may require extra
bolus of rapid acting IA if substantial snacks, i.e. > 15 g CHO,
consumed between meals.
Exercise
• • Dose of rapid-acting IA may need to be d for exercise, i.e. as for
soluble insulin. This will depend on changes in CHO intake,
strenuousness and duration of exercise, and time between injections
and exercise.
• • Blood glucose before and after exercise should guide adjustments in
dose of rapid-acting IA.
• • Do not give insulin bolus if extra CHO has been taken to
compensate for the effect of exercise.
DM IN ICU
• Hypoglycaemia
• DKA
• COMPOSITION
Hypoglycaemia
• Whipple triad
RBG < 70
symptoms of hypoglycemia
improvement after glucose intake
Causes
• Too much insulin or oral hypoglycaemic medication.
• Missed or delayed meal or snack.
• Meal or snack providing insuffi cient carbohydrate.
• Strenuous or prolonged physical activity.
• Consuming too much alcohol or drinking on an empty stomach.
• Occasionally, no obvious cause.
Symptoms
• Symptoms vary between individuals and with the severity of the
hypoglycaemia:
• Hunger.
• Sweating.
• Anxiety or irritability.
• Fast pulse or palpitations.
• Tingling lips.
• Blurred vision.
Signs of a more severe hypoglycaemia:
• Diffi culty in concentrating.
• Vagueness or confusion.
• Irrational behaviour.
Treatment
• Acute hypoglycaemia should be treated with 10–20 g of glucose orally
in conscious patients, i.e. glass of fi zzy drink containing glucose or
fruit juice, > 3 glucose tablets, 5 sweets, e.g. jelly babies
• If unconscious, no oral intake should be given,iv glucose ,, inject
glucagon if available and trained to do so or call for ambulance.
Monitoring of glycaemic control
• Glycosylated haemoglobin (HbA 1c) reflects blood glucose levels over
the preceding 3 months.
• Values:
<6.5 %are considered a desirable target for most patients with
type 1 and type 2 diabetes, and are associated with a reduced risk of
complications.
People with severe risk of hypoglycaemia should aim for a target of
<7.5 % .
DKA

• DEF:
• MANAGEMENT :
FLUID ,, INSULIN
COMPOSITION
Proteins:
Daily requirements of proteins-.8-1.2 g/kg
Normal Metabolism
Hyper catabolism 1.2-1.6gm/Kg
Carbohydrate:
It Provides up to 60-70% of total calories It provides 3.4 Kcal /g of glucose should not
exceed 5 mg/kg/min. generally 50: 50
Lipids:
Lipid emulsion provides 30-40% of total energy.
It provides 9.3 Kcal/gm should not exceed 1.5 g lipids/kg/day
Micro nutrient :vitamins and trace element
Case calculation
• Patient 70 kg
• Requirement 30 kcal /kg per day
• Caloric requirement =70*30=2100
• 60%CHO equals 1260
• 1260 /4 =315 gm
• 40% FAT equals 840
• 840 / 9 =93 gm
• Protien 1 gm /kg
• Patient needs 80 gm protein