COMPLICATION

OF

DIABETES MELLITUS
KLINIK DIABETES TERPADU RS ISLAM KLATEN

When you have diabetes, youre:

Twenty times more likely to develop KIDNEY disease Four times more likely to have a STROKE Four times more likely become BLIND Two to four times more likely to have a HEART attack

Researchers continue to make great progress what triggers complication DM & how to manage or prevent them
Blood sugar close to normal reduce risks of complication Controlled blood sugar not to late to start (As soon as begin managing blood sugar level slow the progression of complication & reduce chances of developing still more healthn problems

COMPLICATIONS of DM
ACUTE

1.Diabetic ketoacidosis (DKA)

2.Hyperglycemic hyperosmolar state (HHS) 3.Hypoglycemia 4. Lactic acidosis CHRONIC 1.Microangiopathy (retinopathy, nephropathy, neuropathy, Cardiomyopathy, Diabetic foot, etc) 2.Macroangiopathy (Heart attack/IMA, Stroke, PAD)

Acute complications
Medical emergencies, complications are these spark medical emergencies requiring immediate attention. This include low blood sugar, high blood sugar and excessive blood acids.

PATOFISIOLOGI KAD & HHS

laktic acid

DKA
Occurs when muscle cells become so starved for energy that body takes emergency measures & breaks down fat toxic acids as ketones Most common type 1 DM insufficient insulin to adjust raise of blood sugar Cause by extreme stress or illness Infection body produce adrenalin works against insulin Forget to take insulin

Sign & symptom of DKA

Deep, rapid breathing Sweet, fruity smell on breath Loss of appetite Nausea Fatigue Vomiting Weakness Fever Confusion Stomach pain Drowsiness Weight loss

Clinical presentation
Lost more than 5% body weight More than 35 breaths a minute Cant control blood sugar Become confused Nausea and vomiting

What should you do?

Check ketones if feeling especially stressed or blood sugar persistently above 240mg/dL High ketones in blood ketones excreted in urine. High ketones in urine must treatment & stay in hospital DKA can lead into coma and posibly death.

Treatment
Replenishing lost fluids through i.v. line Insulin combined with glucose, injected into iv stop making ketones Gradually blood sugar level back to normal, if quickly can produce swelling in the Brain

HHS

Blood sugar reaches such a high level that blood become thick and syrupy (level >600 mg/dL) Cells cant absorb much blood sugar, the sugar passed from blood to urine draws tremenous amounts of fluid from body and produces dehydration Common in type 2 DM, especially who dont monitor blood sugar and who dont know have DM Trigger factors: high-dose steroid, diuretics, infection, illness, stress or drinking excessive alcohol

HHS, sign & symptom

Excesive thirst Increased urination Weakness Leg cramps Confusion Rapid pulse Convulsions Coma

What should you do?

Check blood sugar level (> 600mg/dL) Emergency treatment can correct the problem within hours Give intravenous fluids to restore water to the tissue Short acting insulin to help cells can absorb glucose Without prompt treatment can be fatal

Hypoglycemia
Blood sugar level <60mg/dL Basssically from too much insulin and too little glucose in blood Most common among people taking insulin or oral medication to release or action of insulin Reasons: Skipping the meal Exercising longer or more strenuously than normal Not adjusting your medication to accommodate changes in blood sugar

Sign & symptom of Hypoglycemia

Blood sugar level 40-55mg/dL: Sweating Shakiness Visual disturbances Weakness Hunger Dizziness Nervousness Headache Fast heartbeat Irritability Cold, clammy skin

Sign & symptom of Hypoglycemia

Later symptomp (BG < 40mg/dL) Slurred speech Drunkenlike behavior Drowsiness Confusion Emergency symptoms (BG <20 mg/dL) Convulsions Unconsiousness, wich can be fatal

Hypoglycemia unawareness
Some people had DM for several years dont experience early symptoms of hypo glycemia, such as shakiness or nervousness because chemical changes from long standing DM may mask the symptoms or keep them for occuring This condition may not realize blood sugar is low until later symptoms, such as confusion or slurred speech, set in.

What should you do?

As soon realize blood sugar is low, eat or drink something raise BG level quickly. Example: Hard candy, equal to about five live saving A regular (not diet) soft drink Half a cup of fruit juice Glucose tablets, nonprescription sugar pills made especially for treating low blood sugar

What should you do?

If after 15 minutes continue to experience symptoms, repeat the treatment. If they still, contact the doctor. If lose consiousness or for some other reason are unable to swallow, the treatmen of choice is an injection D 40% or glucagon injection (fast acting hormone contra insulin to stimulate the release sugar into the blood)

Alhamdullillah Thank you for your attention

CHRONIC COMPLICATION Of DIABETES MELLITUS

Chronic complications

Development of other diseases Long-term DM complications are those that develop gradually and that may become disabling or live-threatening. They include nerve, kidney, eye, heart and blood vessel disease

CHRONIC COMPLICATIONS MICROVASCULAR

RETINOPATHY NEPHROPATHY CARDIOMYOPATHY NEUROPATHY

AUTONOMIC

CARDIAC GASTRIC UROGENITAL

CHRONIC COMPLICATION MACROVASCULAR

CHD
24x DEATH 60 %

RISK

CEREBROVASCULAR

STROKE

: 4x

PERIPHERAL VD 40 50 % NON-TRAUMATIC AMPUTATION

Retinopathy

Retina is back part of eye, is nourished by many tiny vessel. The blood vessels are often among the first to be damaged by blood sugar Everyone with type 1 DM & 6/10 type 2 DM developed retinopathy after 20 years Most people only mild vision problems. For others with severe including blindness DM is leading cause blindness in adults (each year 12000 24000 cases)

Nonproliferatif Mild & most common Blood vessel in retina become weak & swell or bulges or fatty deposits Doesnt affect in the vision unless Responsible for sharpest vision Proliferatif Tiny blood vessel are damage, bleed or close off New & fragile of blood vessel in retina may bleed

If bleeding is heavy or occurs in the certain it can obscure your vision New blood vessel (neo vascularisation) also can form scar tissue can push & pull on your retina and distour vision Special treatment by an optalmologist wth Laser or Vitrectomy Important to cath the disease early so that it can be treated

Sign & symptom

Spiders cobweb or tiny specks floating in an eye A gray shadow in the filed vision Blurred vision Blurred word while reading A dark or empty spot in the center vision Dark streaks or red film that block vision Eye pain Flahes or light or rings around objects Srait line that appear distorted Vision loss

How is it Treated? (retinopathy)

Reguler eye examinations to identity problem early Laser procedure to seal weak blood vessel In most cases only one eye is treated at a time may several treatments pain Bleedin in the middle eye need surgical procedure to remove the blood an replace with clear fluid Detached (ablatio) retina by scar tissue requires surgery to position the retina in place

Nephropathy
Inside kidney are million tiny blood vessel filter waste from the blood disposed to urine DM can damage this delicate filtering system, before developed any symptom More 3/10 type 1 DM nephropathy 1/10 type 2 DM nephropathy Type DM younger, longer have DM higher risk of kidney damage

Sign & symptom

Swelling of ankles, feet and hands Shortness of breath High blood pressure Confusion or difficulty concentrating Poor appetite Nausea and vomiting Dry, itchy skin Fatigue

How is treated? (nephropathy)

Treatment depends on how advance the disease is. Keeping BG level normal can prevent your condition from getting worse, possibly improve. ACE inhibitors may help hypertension & heart problem ARB can improve kidney function and decrease microalbuminuria Low pretein diet seems to reduce workload of kidney (consult doctors & dietician) Severe damage with (ESRD) transplant, Hemodialyse or CAPD (continous ambulatory peritoneal dialyse)

Neuropathy
Have an intricate network of nerves runs throughout the body, connecting brain to muscles, skin and other organs. Brain senses pain, control the muscles, and perform automatic task such as breathing and digestion Neuropathy affect 6/10 type 2 DM

Sign & symptom

Many kind of nerve damage Weakened muscles & an unsteady walk Autonomic nerves can increase heart rate & perspiration level In men can interfere to ability erection In sensory nerves damage unable detect sensation such as pain, warmth, coolness and texture

Sign & symptom

Commonly damage often in the legs, less in the arm Tingling feeling, numbness, pain or combination these sensation Burning pain comes and goes Discomfort as a crawling sensation Begin in tips of toe or finger or both and gradualy spread upward Damage nerve in toe, if untreated can lose of all sensation high risk for injury without realizing

Sign & symptom

Foot care very important If lost feeling in the feet and not to check them each day, may not realize have a cut or open wound until serious infection The main cause of amputations in DM 60.000 amputation each year in DM

How is it treated? (neuropathy)

Good BG control will reduce your symptoms To relieve pain: pain reliever or antidepressantor antiseizure medication Capsaicin cream (hot pepper extract) Other therapy: accupuncture, biofeedback and relaxation techniques Type 2 DM patients dont burn themself when bathing or electric blanket or heating pad. Guard against frost bite in cold temperature

Heart and blood vessel

DM dramatically increased your risk of developing one of many cardiovascular problems, including: Chest pain (angina) Heart attack Stroke Narrowing of the arteries (legs and brain poor blood circulation) peripheral vascular disease High blood pressure DM can damage mayor arteries (supply heart & brain) easier for fatty deposits (plaques) increase pressure in arteries & reduce blood circulation

Sign & symptom

Symptoms heart disease vary. Early stage produce no symptom. Later may include: Shortnss of breath Pain of the chest, jaw or arm Fatigue or weakness Swelling (edema) Lightaheadness Rapid or irreguler heart beat (palpitation) Excessive perspiration People with DM are particular risk for silent (asymptomatic) heart attacks without typical symtomps (painless)

How it is treated?
Many forms of heart disease are treated with medicationto prevent symptom from worsening If accumulation of plaques in the arteries may procedure angioplasty to open arteries sometimes bypass arteries surgery To prevent including healthy diet, more exercise, stopping smoking, losing weight (if over weight)

Risk of infection
High BG impaired function the immune cells to fight off germ & bacteriainfection Location: mouth, gums, lungs, skin, feet, bladder and genital High BG damage nerve otherwise alert infection damage nerves to control bladder sensation fail alert bladder is full overstreched lose muscle tone ability yo empty completely bacteria may grow infection

Sign and symptom

Many vary depending location of infection Low grade fever Gum : red and bleeding Bladder: frequent urination, urgency and burning sensation Vagina: itching &/or discharge in vagina Foot: redness & pus are warning an infection

How it is treated?
Antibiotic to kill bacteria A foot injury: procedure to clean the injured area and remove infected tissue Reduce risk of gum disease by brushing and flossing the teeth regularly Reduce risk of bladder infection by going the bathroom regularly and making sure to empty the bladder

IMPOTENCE in DM

Refers: inability an erection of the penis or inability an erection long enough for sexual intercourse Physical: excess blood sugar can damage the nerves & blood vessel no longer communication nerves to small blood vessel & large blood vessel narrowed or blocked not enough blood to erection (common in DM) Psychological: anxiety, stress or depression impaired Brain and Hormones respond Medication: drugs for hypertension, anxiety & depression

MEDICATION of IMPOTENCE
I. Sildenafil (Viagra, Androz, Edegra,Silagra) isnt effective for everyone 1hour before activity effective 4 hours II. Alprostadil (synthetic of prostaglandin E-1) not a pill self intraurethral (a grain rice) or self injection therapy (5-20 minutes before and 1 hour erection) III. Vacuum device IV. Penile implant a. semirigid, benabled rod (permanent erection) b. inflantable (with pump in scrotum produce an erection only when you want) V. Counseling (if psychologycal factors)

Preventing complication
Tight BG control normal or near-normal Diabetes Control and Complication Trial (DCCT): Tight BG control reduce 50% risk of many complication United Kingdom Prospective Diabetes Study (UKPDS): Keep BG normal: 1/4 fewer complications (eyes, kidneys and nerves) and reduce risk of heart disease Kumamoto study: the intensive insulin therapy have delay in the start and progression of eye, kidney and nerve complication

SELF CARE: Reducing risk of complication

Have a yearly physical examination Get a yearly eye examination See the dentist regularly Keep up to date vaccination (flu, pneumonia) Care the feet Dont smoke Take a daily aspirin Monitor blood pressure Manage stress

THANK YOU