Write the acute complications of Insulin dependent diabetes mellitus and outline their management.

Diabetic Ketoacidosis (DKA)

DKA results from a severe deficiency of insulin coupled with an excess of counter-regulatory hormones (glucagon, cortisol, growth hormone, epinephrine). This leads to hyperglycemia, lipolysis, and the production of ketone bodies.

Etiology:

• Missed or inadequate insulin doses
• Infection (pneumonia, urinary tract infection)
• Illness or surgery
• New onset Type 1 Diabetes

Clinical Features:

• Hyperglycemia (blood glucose >250 mg/dL)
• Ketosis (moderate to large ketones in urine or serum)
• Metabolic acidosis (arterial pH <7.3, bicarbonate <15 mEq/L)
• Dehydration
• Kussmaul respirations (deep, rapid breathing)
• Abdominal pain, nausea, vomiting
• Altered mental status

Diagnosis:

Diagnosis is based on the triad of hyperglycemia, ketosis, and metabolic acidosis. Laboratory findings include elevated blood glucose, elevated serum ketones, low bicarbonate, and anion gap acidosis.

Management:

• Fluid Resuscitation: Initial bolus of 0.9% saline followed by maintenance fluids based on hydration status.
• Insulin Therapy: Continuous intravenous regular insulin infusion (typically 0.1 unit/kg/hour) until glucose levels fall to around 200-250 mg/dL.
• Electrolyte Correction: Potassium is often depleted and requires careful replacement. Phosphate and magnesium may also need correction.
• Monitoring: Frequent monitoring of blood glucose, electrolytes, arterial blood gases, and mental status.
• Identify and Treat Precipitating Cause: Address underlying infection or illness.

Hypoglycemia

Hypoglycemia is defined as a blood glucose level below 70 mg/dL. It is a common complication of insulin therapy, resulting from an imbalance between insulin dose, carbohydrate intake, and physical activity.

Etiology:

• Excessive insulin dose
• Missed or delayed meals
• Increased physical activity
• Alcohol consumption
• Impaired renal or hepatic function

Clinical Features:

Symptoms are categorized into autonomic (tremor, sweating, palpitations) and neuroglycopenic (confusion, dizziness, seizures, coma).

Diagnosis:

Diagnosis is based on plasma glucose levels (<70 mg/dL) and associated symptoms.

Management:

• Mild Hypoglycemia (conscious, able to swallow): 15-20 grams of rapid-acting carbohydrates (glucose tablets, juice, regular soda). Recheck glucose after 15 minutes and repeat if necessary.
• Severe Hypoglycemia (unconscious or unable to swallow): Glucagon injection (1 mg intramuscularly or subcutaneously) or intravenous dextrose (25-50 mL of 50% dextrose).
• Prevention: Education on insulin adjustment, meal timing, and recognizing symptoms of hypoglycemia.

Complication	DKA	Hypoglycemia
Blood Glucose	>250 mg/dL	<70 mg/dL
Ketones	Present (moderate to large)	Absent
Arterial pH	<7.3	Normal
Treatment	Fluids, Insulin, Electrolytes	Carbohydrates, Glucagon, Dextrose