Short Term Complications:

• Hypoglycemia
• Diabetic Ketoacidosis

HYPOGLYCEMIA or insulin reactions happen when the blood sugar gets too low. In diabetics a blood sugar of less than 80mg/dl should be treated as hypoglycemia. This is one of the most important and frequent complications of diabetes. The brain needs glucose to function properly. If the blood glucose is too low, the brain begins to suffer.

What causes Hypoglycemia (Insulin Reactions)?

Usually one or more of these things causes hypoglycemia:

• Too much insulin
• Not enough food
• Too much vigorous exercise

What are the signs of a mild insulin reaction?

Signs of an insulin reaction vary between persons or even vary at different times for the same person. They depend on whether the drop in blood sugar is slow or rapid. Symptoms may be due to low blood sugar in the brain or due to the adrenaline that the body produces in an attempt to raise the blood sugar. Some signs include:
Hunger, weakness, dizziness, sleepiness, mood change, shakiness and sweating.
You should know all the signs, because an insulin reaction may cause you to feel one way this time and another way next time.

What should you do if you have Hypoglycemia signs?

First, if you are exercising -- stop and rest.
Then, eat some kind of fast-acting sugar, like a fruit exchange.
¨ 1/2 cup unsweetened fruit juice or 125 ml of cola (not diet)
¨ 3 sugar cubes or 3 tsp. sugar

You should begin to feel better in 10 to 15 minutes. If not, then eat another fruit exchange.
If it is longer than 1 hour before your next meal, you should eat a starch exchange and a protein exchange also. These foods will help keep your blood sugar up until your next meal.
You could always carry some kind of fruit exchange with you, like sugar cubes or candy. If you do not treat a mild insulin reaction, your blood sugar could get even lower.

How should you treat a severe Insulin reaction?

During severe hypoglycemia, friends or parents will need to help in the following way:

• Place small amounts of honey or sugar syrup inside the mouth (between the cheek and gum).
• If the child is not fully conscious, never try to give sugar in solid form, the child may aspirate.
• Mix and give Glucagon injection.
  Glucagon will let stored sugar out of the liver and the blood sugar will go up. It takes 15-30 minutes for glucagon to work.
• If the blood sugar is not coming up – take the child to a hospital for help.
• When the child wakes up, remember to feed with a longer acting carbohydrate (like a starch, or milk).
• After having an insulin reaction and treating it, the blood sugar may rebound to high levels (250-300mg%)
• Let you physician know about severe insulin reactions.

How you can prevent Hypoglycemia?

• Always have meals and snacks on time.
• If you know that you will be exercising extra hard, eat an extra starch exchange before you begin.
• If your blood sugar is low just before a meal, eat the fruit exhange at that meal first.
• Always carry a fast-acting sugar with you just in case.
• Always keep glucagon at home.
• If you are having frequent insulin reactions, let your endocrinologist know. You may need an insulin dose change or a change in your meal plan.

Ketoacidosis is a condition, which may occur in patients suffering from Type I or Insulin Dependent Diabetes Mellitus. It can also occur in patients with Type 2 or Non Insulin Dependent Diabetes mellitus in conditions of severe stress.
Ketones are acids (one of them being acetone), which are produced in the body when the insulin is not enough. Large amounts of ketones in the blood make the blood acidic, leading to a dangerous condition called Ketoacidosis.

Metabolism of glucose and fats:

Glucose is used by the body to provide energy, but requires the presence of insulin to do so. Even if the glucose level is very high, the body cannot use it in the absence of insulin. In this situation Fat is used to provide energy, since this process does not require the presence of insulin. When fat is used to provide energy, a part of it is converted to ketones by the liver. The excess of ketones, spills over in the urine, and this is called ketonuria. In the presence of high blood glucose, this means that your Diabetes is out of control and you are not getting enough insulin.

Presence of ketones in the urine can be detected by strips, which are similar to the ones used for detecting glucose in the urine.

Therefore, if insulin in the body is deficient or ineffective, the excess of glucose
cannot be used to provide energy. Fat acts as the alternative source of energy in
these situations and leads to ketone formation.

Conditions in which this occurs:

• Absence of insulin, due to missing of insulin shots, in case of Insulin Dependent
  Diabetics.
• Stress of any kind, such as physical illness, infections, emotional upsets cause secretion of the stress hormones such as Adrenaline, Cortisone etc.
  These stress hormones have an anti insulin effect ie they interfere with the effect of
  insulin, and therefore the patient’s usual dose of insulin is not effective enough in these
  situations.
• Starvation When people don’t eat enough, glucose is not available for producing
  energy. Starvation usually results in very small amounts of ketones.
• Insulin reaction (low blood sugar )

The consequences of high ketone levels in blood and in the urine:

• Ketones produce a lot of acid in the body, which cannot be excreted adequately because
  of the dehydration.
• Rapid and deep breathing
• Unconsciousness

This condition is called ketoacidosis and is a very severe condition, which can be life threatening if not treated in time.

If ketosis is detected at an early stage, then ketoacidosis can be prevented.

For detection at an early stage:

• Check urine for ketones with a ketostix everytime the blood glucose is greater than
  250mg/dl.
• During infections or emotional stress, check blood glucose and urine ketones every 6
  Hours at least
• If blood glucose is running high, extra insulin should be given to bring it down to normal
• Never miss your insulin shot
• Do not decrease the dose of insulin during sickness, assuming that the appetite is poor, without checking the blood sugar. This is a mistake made very often by patients during sickness.
  

How to deal with ketonuria and to prevent ketoacidosis?

Hyperglycemia (high blood sugar) with Ketonuria is a potential emergency, which if not corrected on time may lead to hospitalisation and coma. Contact your endocrinologist as soon as you have detected ketones in your urine and initial management can be done at home under his/her guidance.
For this condition we need to give extra insulin to overcome its absence or ineffectiveness. Fast acting insulin should be used for quick results. Hence regular insulin would be the insulin of choice.

When to stop the extra doses of insulin:

Extra insulin should be stopped, once the blood sugar is below 200mg/dl, even if the urine is testing positive for ketones, because the ketones may take some time to disappear. The insulin acts on the blood sugar and not on the ketones.

Some extra precautions:

• Contact your physician at the outset of ketones in the urine and continue to keep in touch, so that you can get help.
• Drink plenty of water to help get rid of the ketones from the blood, through the urine.
• Continue monitoring the blood sugar and urine ketones for a couple of hours after
  the blood sugar has normalized.
• Do not delay treatment. The longer you wait, the harder it will be to get rid of the
  ketones. Remember! A stitch in time saves nine!
• Do not over-treat yourself by giving too much insulin. Hence contact and advise from your physician is important.
• Vomiting may occur frequently during ketosis. An antiemetic can be used for this purpose.
• REMEMBER! GOOD LONG TERM CONTROL OF DIABETES IS
  IMPORTANT FOR NOT ONLY CHRONIC, BUT ACUTE COMPLICATIONS
  TOO!

Patients with good control have greater resistance to development
of ketoacidosis and in poorly controlled diabetics, even minor stress may precipitate ketosis.