Any time the body chemistry is out of balance, there are bound to be adverse changes in body tissue. The environment, the things you eat, the stresses you are under, and whatever illnesses or disabilities you may be fighting all make a difference in the physiological functioning of your body (that is, the way your body responds). If you have a way to control the “stimulators” of these changes, it will be possible for you to minimize the damage that such changes can cause. So it is with diabetes mellitus. The body cells are accustomed to only so much glucose in the system. If there is too much or too little, changes take place in cell function, size, and structure.

There are three series of changes that occur with the person who has diabetes: acute changes, intermediate changes, and chronic changes. Acute changes, or complications, are diabetic ketoacidosis, hypoglycemia, and hyperglycemic hyperosmolar nonketotic syndrome. Intermediate complications are those involving illness, surgery, pregnancy, and travel. Chronic complications involve the nerves (neuropathy), the kidneys (nephropathy), the eyes (retinopathy), and macroangiopathy of the heart and large blood vessels (cardiomyopathy: peripheral, cerebral, and cardiovascular). Chronic complications are noticeable by pain, numbness, inability to see, inability to go to the bathroom, and inability to otherwise function. Retinopathy, nephropathy, neuropathy, and cardiomyopathy have association, directly or indirectly, with small blood vessels.

Acute Complications

Diabetic Ketoacidosis

Diabetic ketoacidosis is preceded by diabetic ketosis, which itself is preceded by hyperglycemia. As already discussed, hyperglycemia can occur when there is an absolute lack or relative unavailability of insulin. Diabetic ketosis occurs when insulin is deficient and glucose is no longer able to get into the cells. When this occurs, an alternate source of energy is needed. The result is the production of ketone bodies from free fatty acids. Diabetic ketoacidosis, the most severe state, occurs when an imbalance due to a severe or prolonged insulin deficiency leads to dehydration and a chemical (electrolyte) imbalance. (See Table 10.1 for signs and symptoms of diabetic ketoacidosis.)

Diabetic ketoacidosis is a serious condition. The blood-glucose levels are not necessarily extremely high (for example, in the case of an infant, the blood glucose value could be 190 mg/dl [10.5 mmol]). Usually, however, the level is in the range of 300 to 900 mg/dl (16.6 to 50 mmol). The production of ketones from the fat breakdown makes the body more acidic. This is when the acute problem occurs, since the body cannot exist if it is too acid or too alkaline. Acidity is manifested or noted by chemistry (biochemically) and by labored breathing (Kussmaul, or heavy and labored respirations). Kussmaul respiration is the body’s attempt to break down and blow off some of the acid in the system (carbon dioxide and its earlier form, carbonic acid).

Diabetic ketoacidosis is treated with intravenous fluids (to dilute the glucose levels in the system and rehydrate the dehydrated person), with insulin (to aid in helping glucose get into the cells), and with chemicals called electrolytes (usually potassium, sodium, phosphates, and bicarbonates). Two of the most common chemicals needing replacement are potassium and sodium. These are involved in cellular functions related to electrical changes in the body, particularly in the heart and the brain. The first fluids given are called “plasma expanders,” which can be anything from blood to saline. Normal saline (a body-balanced salt-and-water solution) is usually the fluid of choice.

Once the blood-glucose levels drop to a certain point (that is, about 300 mg/dl [17 mmol]), the body needs some fuel so that it will not call on more ketones (ketogenesis) for energy and hypoglycemia will not occur. Glucose is added as part of the saline solution (D5 or D10 usually in half of normal saline). The choice depends on whether there is a balance in the saline level in the body, as determined (analyzed) by frequent electrolyte analyses by the lab. Potassium is almost always added to the intravenous fluids, as are other chemicals, if such chemicals do not rebalance in the rehydration process. Insulin is also given, usually intravenously, until the blood-glucose levels are near normal and more stable.

Table 10.1 Diabetic Ketoacidosis from Hyperglycemia