Diabetes Complications Guide | GCC Nursing Platform

DKA — Diabetic Ketoacidosis

🔬 Diagnostic Criteria

Parameter	Threshold
Blood Glucose	>11 mmol/L
Blood Ketones	≥3 mmol/L
Urinary Ketones	≥++ (alternative if blood ketones unavailable)
pH	<7.3
Bicarbonate	<15 mmol/L

All three criteria must be met: hyperglycaemia + ketonaemia + acidosis.

⚖️ DKA Severity Calculator

Arterial pH Bicarbonate (mmol/L) Blood Ketones (mmol/L)

Severity	pH	Bicarbonate	Ketones	Management
Mild	7.25–7.30	15–18 mmol/L	3–6 mmol/L	Ambulatory management possible
Moderate	7.00–7.24	10–14 mmol/L	3–6 mmol/L	Ward admission
Severe	<7.00	<10 mmol/L	>6 mmol/L	HDU / ICU

💉 Fixed-Rate Insulin Infusion (FRII)

Rate: 0.1 units/kg/hr Actrapid in 0.9% NaCl (1 unit/mL)
Continue until: pH >7.3 AND bicarbonate >18 AND ketones <0.6 mmol/L
Do NOT stop insulin simply because glucose normalises
When glucose falls to <14 mmol/L: add 10% dextrose at 125 mL/hr alongside continued 0.9% NaCl

Critical: Stopping insulin prematurely is a leading cause of DKA-related mortality. The insulin is treating acidosis, not just hyperglycaemia.

🫗 IV Fluid Protocol — 0.9% NaCl

Step 1

1 L

over 1 hour

Step 2

1 L

over 2 hours

Step 3

1 L

over 2 hours

Step 4

1 L

over 4 hours

Step 5

1 L

over 4 hours

Step 6

Reassess

adjust for age, renal/cardiac status

Adjust fluid rates in elderly patients and those with cardiac or renal impairment to avoid fluid overload.

🧪 Potassium Replacement

Recheck serum K+ every 1–2 hours

Serum K+	Action
< 3.5 mmol/L	40 mmol/hr K+ replacement — senior review required before giving
3.5–5.5 mmol/L	Add 40 mmol to each litre of IV fluid
> 5.5 mmol/L	No K+ replacement — recheck in 1 hour

Do not give IV insulin if K+ <3.5 mmol/L until potassium corrected — risk of fatal arrhythmia.

✅ Resolution Criteria & Transition to SC Insulin

Resolution criteria (all must be met)

pH >7.3
Bicarbonate >18 mmol/L
Blood ketones <0.6 mmol/L
Glucose stabilising

Transition protocol

Patient eating and drinking
Give long-acting SC insulin (basal dose)
Wait 30–60 minutes (overlap period — essential)
Stop FRII

Never stop FRII before giving SC insulin — rebound ketosis can occur within 30 minutes.

HHS — Hyperosmolar Hyperglycaemic State

🔬 Diagnostic Criteria

Parameter	Threshold
Blood Glucose	>30 mmol/L
Plasma Osmolarity	>320 mOsm/kg
Ketonaemia	Absent or minimal
Acidosis	Absent (pH >7.3)

🧮 Osmolarity Calculator

Formula: 2(Na + K) + Urea + Glucose

Sodium Na+ (mmol/L) Potassium K+ (mmol/L) Urea (mmol/L) Glucose (mmol/L)

⚖️ Key Differences: HHS vs DKA

Feature	HHS	DKA
Typical patient	Elderly T2DM	T1DM (any age)
Onset	Days to weeks	Hours
Glucose	>30 mmol/L	>11 mmol/L
Ketones	Absent/minimal	≥3 mmol/L
Acidosis	No	Yes (pH <7.3)
Fluid deficit	8–10 L	3–6 L
Osmolarity	>320 mOsm/kg	Usually normal–mildly elevated
VTE/stroke risk	Very high	Moderate
Initial presentation	Often first diagnosis of DM	Known T1DM usually

🫗 Fluid Protocol — Slower Than DKA

Start: 0.9% NaCl 1 L over 1 hour, then reassess
Correct osmolarity at <10 mOsm/kg/hr to avoid cerebral oedema
Total correction over 48–72 hours
As glucose falls, sodium rises — monitor closely
Switch to 0.45% NaCl if plasma sodium is rising rapidly (>150 mmol/L)

Too-rapid correction of osmolarity can cause cerebral oedema and osmotic demyelination syndrome.

💉 Insulin in HHS

Do NOT start insulin until 1–2 L fluid replacement given
Low-dose FRII: 0.05 units/kg/hr (half the DKA dose)
Avoid rapid glucose fall — risk of cerebral oedema
If glucose not falling with fluids alone, then consider insulin

Starting insulin too early in HHS causes rapid osmotic shifts — fluids must come first.

🩸 Anticoagulation & Monitoring

Mandatory anticoagulation

Enoxaparin 40 mg SC daily — all HHS patients
High VTE risk: hyperosmolar state + elderly + immobile
Elevated stroke risk — neuro observations required

Monitoring frequency

Blood glucose: hourly
Electrolytes (Na, K, urea): every 2 hours
Calculated osmolarity: every 4 hours
Neurological observations: every 2 hours
Fluid balance: continuous

Hypoglycaemia

📉 Definition & Symptom Categories

Hypoglycaemia: Blood glucose <4.0 mmol/L (<70 mg/dL)

Category	BGL	Symptoms
Autonomic (Early warning)	3–4 mmol/L	Sweating, palpitations, tremor, anxiety, hunger, pallor
Neuroglycopenic (Brain glucose deprived)	<3 mmol/L	Confusion, slurred speech, weakness, vision changes, seizure, coma
Hypoglycaemia Unawareness	Variable	No autonomic warning symptoms — common after many years of DM. Risk of sudden severe hypoglycaemia.

🩹 Severity Classification & Treatment

Level 1 — BGL 3.0–3.9 mmol/L (Alert & Conscious)
Give 15 g fast-acting carbohydrates:
• 4 glucose tablets OR 150 mL fruit juice OR 3 jelly beans
Recheck BGL in 15 minutes. Repeat if still <4.0 mmol/L.

Level 2 — BGL <3.0 mmol/L (Mildly Confused)
• Oral dextrose gel (buccal absorption) if safe to swallow
• Then 15 g carbohydrates once tolerating oral intake
• Do NOT give oral glucose if swallow is unsafe

Level 3 — Unresponsive / Seizure
• IV 50% dextrose: 50 mL IV push (adults)
• OR Glucagon 1 mg IM (if no IV access)
• Recovery snack once conscious: 20 g long-acting carbohydrate
• Investigate and document cause

📏 Rule of 15

15g

Fast-acting carbohydrates

15 min

Wait then recheck BGL

Repeat

If BGL still <4.0 mmol/L

After BGL normalises: give 20 g long-acting carbohydrate snack (e.g. 2 biscuits + milk, banana) to prevent rebound hypoglycaemia.

💊 Glucagon Auto-Injector

Position patient in recovery position (seizure or unconscious)
Remove from case — do NOT shake
Remove needle cap
Inject into outer thigh or upper arm IM (through clothing if needed)
Hold in place for 5 seconds
Call emergency services simultaneously
When patient responds: give 20 g carbohydrate snack

Who should carry glucagon: All T1DM patients + T2DM on insulin at home — especially those with hypoglycaemia unawareness.

🌙 GCC Context: Ramadan Hypoglycaemia

Patients on insulin or sulphonylureas face elevated hypoglycaemia risk during Ramadan fasting
Cultural and religious pressure to complete the fast — patients may not report symptoms
Islamic fatwa supports breaking the fast for medical necessity — nurse education role is critical
Timing of medications must be re-aligned to Iftar and Suhoor
Pre-Ramadan structured education programme recommended for all insulin-dependent patients

Nurse's role: Proactively identify high-risk patients before Ramadan, provide written break-fast guidelines (BGL <3.9 or >16.7 = break fast), and coordinate endocrinology review.

Chronic Complications of Diabetes

🌍 GCC Epidemiology

UAE, Kuwait, and Saudi Arabia rank among the top 10 countries globally for diabetes prevalence
Diabetes accounts for approximately 17% of all deaths in the GCC
GCC has the highest rates of diabetic ESRD (end-stage renal disease) requiring dialysis worldwide
Diabetic retinopathy is the leading cause of blindness in GCC working-age adults

Monitoring targets: HbA1c <53 mmol/mol (7%) standard | <48 mmol/mol (6.5%) for newly diagnosed T2DM without complications

❤️ Macrovascular Complications

Leading cause of death in T2DM. Accelerated atherosclerosis driven by hyperglycaemia, dyslipidaemia, hypertension.

Condition	Key Points	Nurse Actions
Coronary Artery Disease / MI	2–4× higher risk than non-diabetic; may present silently (silent MI)	Monitor BP, lipids, ECG; aspirin adherence; statins
Stroke / TIA	2–4× higher risk; lacunar infarcts common	FAST assessment; atrial fibrillation screening; anticoagulation review
Peripheral Arterial Disease	Claudication, absent pulses, critical ischaemia	ABI measurement; wound care; vascular surgery referral

🫘 Diabetic Nephropathy

Begins with microalbuminuria → macroalbuminuria → declining eGFR → ESRD
Annual urine ACR (albumin:creatinine ratio) and eGFR monitoring
ACEi / ARB are nephroprotective — prescribe even in normotensive patients with proteinuria
GCC: highest rates of diabetic ESRD globally — early detection is critical
Target BP <130/80 mmHg in diabetic nephropathy

SGLT2 inhibitors (empagliflozin, dapagliflozin) have proven cardiorenal protective effects — review with prescribing team.

👁️ Diabetic Retinopathy

Leading cause of preventable blindness in working-age GCC adults
Annual ophthalmology review — even without visual symptoms (early retinopathy is asymptomatic)
Background → pre-proliferative → proliferative retinopathy progression
Treatments: laser photocoagulation, intravitreal anti-VEGF injections (ranibizumab, bevacizumab)
Tight glycaemic and BP control slows progression

Sudden visual loss or floaters = urgent ophthalmology referral (vitreous haemorrhage / retinal detachment).

⚡ Diabetic Neuropathy

Peripheral Neuropathy

Symmetrical "stocking-glove" pattern — starts in feet
Painful: burning, electric, worse at night
Loss of protective sensation → undetected injury → ulceration

Autonomic Neuropathy

Gastroparesis: delayed gastric emptying, nausea, vomiting, erratic glucose control
Orthostatic hypotension: fall risk — measure lying/standing BP
Bladder dysfunction: urinary retention, overflow incontinence
Erectile dysfunction: early marker in men

Pharmacological Management

Drug	Mechanism	Notes
Gabapentin	Calcium channel modulation	Start low, titrate; sedation, dizziness
Duloxetine (SNRI)	Noradrenaline/serotonin reuptake	First-line in many guidelines
Amitriptyline (TCA)	Pain modulation	Anticholinergic side-effects; use low dose
Pregabalin	Calcium channel modulation	Effective but higher abuse potential

🦶 Diabetic Foot

Annual Foot Examination

Monofilament testing (10 g) — 10 sites per foot for protective sensation
Vibration sense (128 Hz tuning fork) — great toe
Ankle Brachial Index (ABI) — peripheral arterial disease screening
Inspection: callus, deformity, nail changes, inter-digital maceration, ulceration
Pulse assessment: dorsalis pedis + posterior tibial

High-Risk Foot

Neuropathy + ischaemia + deformity = HIGH RISK → refer to podiatry + multidisciplinary foot clinic

Patient Education

Inspect feet daily (use a mirror for the sole)
Wash with lukewarm water — test temperature with elbow, not feet
Dry carefully between toes
Never walk barefoot — even indoors
Wear properly fitted footwear — no tight shoes, sandals with straps
Trim nails straight across — refer podiatry if unsure
Report any wound or new pain immediately — do not self-treat

Sick Day Rules

🤒 SICK Rules — Insulin-Dependent Patients

Letter	Rule	Detail
S	Sugar	Test BGL every 1–4 hours. If BGL >14 mmol/L, test blood ketones. Keep a log.
I	Insulin	NEVER stop insulin when unwell — even if not eating. The liver continues to release glucose during illness.
C	Carbohydrates	Maintain carbohydrate intake. If vomiting, use liquids: fruit juice, regular (non-diet) cola, oral rehydration solution.
K	Ketones	If ketones ≥3 mmol/L AND vomiting AND unable to eat/drink = seek emergency medical help.

SICK rules apply to all insulin-dependent patients — T1DM and insulin-requiring T2DM.

Ramadan Management

🌙 Pre-Ramadan Review & Medication Adjustment

Break-Fast Rules (patient must break fast if)

BGL <3.9 mmol/L — hypoglycaemia

BGL >16.7 mmol/L — hyperglycaemia

Feeling unwell — symptoms of DKA, dehydration

Insulin Adjustments for Ramadan

Reduce evening long-acting insulin by 20–30% at Suhoor (pre-dawn meal)
Adjust rapid-acting insulin timing: pre-Iftar and pre-Suhoor
Omit or reduce lunchtime doses (no midday meal)
Sulphonylureas: consider dose reduction or switch — high hypoglycaemia risk
SGLT2 inhibitors: consider withholding during Ramadan (DKA risk in fasting state)

Religious context: Islamic scholars (fatwa) support breaking the fast when there is genuine medical necessity. The nurse plays a vital role in empowering patients with this knowledge.

📊 Ramadan Fasting Risk Stratifier

Diabetes Type Most recent HbA1c Recent hypoglycaemia episodes (last 3 months) Established complications