Diabetes and myocardial infarction

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001 285 2486-2497. Haffner SM, Lehto S, Ronnemaa T, Pyolora K and Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in non-diabetic subjects with and without...

Diabetes and surgery

Diabetes and Surgery, in The Diabetes Annual 4, Alberti KGMM, Krall LP, Editors. 1988, Elsevier Amsterdam. pp. 248-271. Hoofwerf BJ. Postoperative management of the diabetic patient. Med Clin North Am 2001 85 1213-1228. Marks JB and Hirsch IB. Surgery and diabetes mellitus, in Current Therapy of Diabetes Mellitus, DeFronzo RA, Editor. 1998, Mosby St Louis. pp. 247-254. Mesotten D and Van den Berghe G. Clinical potential of insulin therapy in critically ill...

Pathophysiology

As discussed in Chapter 1, the primary cause of ketoacidosis is an absolute or relative insulin deficiency. Briefly, the effects of insulin deficiency and thus an increase in glucagon insulin ratio in the portal circulation together with increases in levels of counter-regulatory hormones catecholamines, cortisol and growth hormone are summarised in Figure 2.1. Elevated levels of ketone bodies result from mobilisation of fatty acids from adipose tissues and their preferential b-oxidation within...

Diagnosis

Delays in initiating therapy may have disastrous consequences. Diabetic ketoacidosis should be considered in any unconscious or hyperventilating patient. If there is any doubt about the severity of the metabolic disturbance in a diabetic patient with ketosis, the arterial pH should be measured. A brief clinical examination focuses on Bedside blood and urine tests should rapidly confirm the diagnosis. Treatment should then be commenced without delay. The initial clinical and biochemical...

Differential diagnosis

The diagnosis is rarely difficult except in younger children, where the acidotic breathing pattern may easily be confused with an Table 2.1 Differential diagnosis of diabetic ketoacidosis in children predominant Physical stress, e.g. intercurrent Alcoholic ketoacidosis infection with transient hyperglycaemia MODY Severe sepsis Renal tubular defects Certain inborn errors of precipitate metabolic decompensation Hyperosmolar non-ketotic coma Type 2 diabetes MODY maturity onset diabetes of the...

Mortality

Diabetic ketoacidosis continues to be an important cause of death among patients with type 1 diabetes. The average mortality rate for ketoacidosis today is quoted as between 5 and 10 per cent although rates vary widely. Experienced centres would expect to report a mortality rate of less than five per cent. Some deaths are inevitable consequences of associated medical conditions such as overwhelming infection. Clearly, the mortality associated with diabetic ketoacidosis has not been abolished,...

Symptoms of hypoglycaemia

Patients with insulin-treated diabetes rely on the physiological responses to hypoglycaemia to alert them to a falling glucose that Irritability and bad temper Sweating Lack of concentration Diminished conscious level Coma prompts them to take action by taking refined carbohydrate Table 4.2 . Symptoms are generated through a combination of 1. sympathoadrenal activation often termed autonomic symptoms and 2. cerebral dysfunction caused by a failing glucose supply to the brain termed...

Pathophysiology of hypoglycaemia in diabetes

Recovery from insulin-induced hypoglycaemia would take many hours if dissipation of insulin were the sole mechanism Figure 4.1 . Additional physiological mechanisms help to resist the glucose lowering effect of insulin and restore blood glucose after an episode of hypoglycaemia. Secretion of counter-regulatory hormones promotes glucose release from the liver opposes glucose uptake in peripheral tissues such as fat and muscle. The most important of these hormones, in terms of recovery from...

Myocardial infarction

Coronary artery disease is the most common cause of death in patients with type 2 diabetes and is an important cause in premature mortality in type 1 diabetes. Diabetic patients tend to have more severe and widespread atherosclerosis than age matched non-diabetic controls. Acute myocardial infarction has a higher immediate and delayed mortality than in non-diabetic individuals, cardiac failure and re-infarction being the main causes of death. The excess mortality among patients with diabetes...

Ketogenesis

Insulin deficiency and catabolic hormone excess, especially of catecholamines, promote lipolysis within adipocytes, wherein triglycerides are converted to three fatty acids and one molecule of glycerol. These effects are mediated via the activity of hormonesensitive lipase triacylglycerol lipase , an enzyme normally regarded as being exquisitely sensitive to inhibition by insulin. Concurrently, re-esterification, i.e. the formation of new triglycerides, within adipocytes is impaired. This...

Severe recurrent or prolonged hypoglycaemia may cause permanent brain damage

Cerebral damage secondary to hypoglycaemia seems to be a relatively rare cause of death in diabetic patients treated with insulin however, insulin-induced death may result from other mechanisms. In a seminal paper, Tattersall and Gill 1991 investigated all unexpected sudden deaths in patients with type 1 diabetes in the UK under the age of 40 during a single year. They identified only two deaths that could be attributed to hypogly-caemic brain damage with certainty. This study highlighted the...

The pharmacokinetics of sulphonylureas is an important determinant of the risk and severity of hypoglycaemia associated

Table 5.2 Risk factors for hypoglycaemia with sulphonylureas Renal insufficiency Hepatic insufficiency Prolonged fasting, e.g. peri-operatively Acute or chronic intercurrent illness Long acting sulphonylureas chlorpropramide, glibenclamide Drugs that interfere with the metabolism of sulphonylureas and prolong their bioactivity see Table 5.3 Short duration of use Elderly patients Polypharmacy Alcohol consumption Other factors include the following. Advanced age. This appears to be an additional...

Role of dialysis

Haemodialysis is classically considered to be the most efficient method, providing both symptomatic and aetiological treatment by eliminating lactate and metformin. This is actually a misconception. Lactate elimination cannot participate in recovery of acid-base balance since lactate per se is not an acid generating substance. Instead, the excess protons from hydrolysis of ATP during anaerobic glycolysis tend to be removed by endogenous buffers, which are regenerated through lactate metabolism....

Discharge planning

It is important to emphasise the need to continue some insulin to avoid relapses of hyperglycaemia and or hyperosmolarity. Subcutaneous insulin treatment should not be initiated too early insulin may be absorbed poorly and erratically from subcutaneous tissue before effective perfusion is re-established. By 12-24 h, once the patient is able to eat and drink, subcutaneous insulin can be commenced, either as a multiple-daily basal-bolus regimen or as twice-daily injections of biphasic insulin....

Labour

Diabetic women have a higher incidence of spontaneous premature delivery than non-diabetic women. Labour and delivery are potentially hazardous events for both mother and infant. Insulin resistance increases during the second and third trimesters, necessitating an increase in insulin doses. All women with tablet treated type 2 diabetes should be treated with insulin during pregnancy. Blood glucose must be monitored carefully during labour. An intravenous infusion of soluble insulin should be...