Page 74 - GALENIKA MEDICAL JOURNAL

are contraindicated. Only emergency interventions, for vital prolonged fasting, malnutrition, circulatory disorders, sep-
indications, should be performed . tic shock, liver and/or kidney and/or adrenal insufficiency,
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more frequently in geriatric patients, unconscious patients,
Hyperglycemia occurs as a result of the combined acti- and hypoglycemia can also be contributed by hypopituita-
on of three processes: increased gluconeogenesis, accele- rism, immobilization, and others. Sometimes, just missing
rated glycolysis, and reduced utilization of glucose by pe- one meal, changing antidiabetic therapy, or the site of in-
ripheral tissues. In DKA is also lipolysis (increased release sulin injection is enough to cause hypoglycemia. The clinical
of fatty acids from adipose tissue into circulation), leading presentation and treatment of hypoglycemia depend on its
to uncontrolled oxidation of fats in the liver, resulting in severity, ranging from mild to very severe (Table 3).
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Table 2. Precipitating factors for the onset of hyperglycemic crises Chronic complications of DM are often present, espe-

Precipitating factors Explanations cially in patients with long-standing disease and those with
Infection pneumonia, urinary tract infection, sepsis poorly controlled diabetes 2, 34 . These include macrovascular
and microvascular complications (diabetic nephropathy, re-
Inadequate anti-diabetic Th insulin, oral hypoglycemics
tinopathy, polyneuropathy). Of particular importance in the
Endocrine disorders Cushing's syndrome, thyrotoxicosis, acromegaly
perioperative period is the presence of DAN (diabetic auto-
Acute pancreatitis, acute intestinal obstruction,
Other diseases nomic neuropathy).
AMI , CVI, heat stroke
Corticosteroids, thiazide diuretics, β-blockers,
Medications Characteristics of DAN, such as silent cardiac ischemia,
chlorpromazine, phenytoin
orthostatic hypotension, gastroparesis, bladder dysfun-
Legend: AMI - Acute Myocardial Infarction; CVI - Cerebrovascular Insult; Th - Therapy.
ction, lack of sweating (thermoregulation disorder), and
the formation of ketone bodies (ketonemia and metabolic others, can result in numerous complications, especially
acidosis) 29, 30 . Hyperglycemia occurs in the presence of risk during major dental surgeries under general anesthesia,
factors (among which infection is the most significant, res- such as acute myocardial infarction, hypotension, aspirati-
ponsible for > 20% of hyperglycemic events) or as a result of on of gastric contents into the lungs (due to delayed gastric
stress (stress hyperglycemia) (Table 2). emptying), urinary retention, ileus, and others .
2
Diabetic ketoacidosis is the most common hyperglyce-
mic complication, with an annual incidence of approxima- Diagnosis and treatment of acute
tely 4.6-8.0 per 1.000 (adult) diabetic patients and a mortali- complications DM in the dental office
ty rate of about 1-5%. In pediatric populations, the incidence
of DKA is much higher, with around 40% (ranging from 26% The clinical picture of acute complications of DM is not
to 67%) of newly diagnosed cases of diabetes in children specific . Symptoms and signs of hyperglycemic crises have
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presenting as DKA, especially among younger children. The many similarities among themselves, as well as with hypo-
mortality rate in pediatric patients is approximately 0.15- glycemia, but also with some other diseases and conditions,
0.30%. The frequency of HHS is much lower (around 1 per so laboratory confirmation is crucial for diagnosis. Therefo-
1.000 patients), but the mortality rate is significantly higher re, it is important to adhere to the recommendations of va-
than that of DKA (5-20%), especially among young obese pa- rious associations (American, European, and others) in den-
tients and those with comorbidities 29, 30 . tal offices and, most importantly, to the National Guide for
the Diagnosis and Treatment of DM issued by the Ministry
Hypoglycemia is the most common and therefore the of Health of the Republic of Serbia 8, 30, 35 . These guidelines,
most significant acute complication of diabetes mellitus among other recommendations, suggest that equipment
from the perspective of dentists. It is more common in for measuring capillary blood glucose should always be ava-
type 1 diabetes mellitus, with estimates suggesting that ilable at sites where any procedures and/or interventions
one-quarter to one-third of insulin-treated patients expe- are performed 8, 36 .
rience severe hypoglycemia at least once a year. Generally,
hypoglycemia is a more severe disorder than hyperglycemia The treatment of hypoglycemia should be tailored to
because some cells/tissues can exclusively use glucose as the severity of symptoms and signs. Mild hypoglycemia is
an energy substrate (e.g., the brain) . Hypoglycemia oc- characterized by symptoms such as hunger, drowsiness,
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curs in the presence of risk factors such as missed meals or nausea, weakness, mild dizziness, and headache. Moderate

Table 3. Severity of hypoglycemia
Level (severity) of glycemia Value of glycemia Notes
Level 1
Mild hypoglycemia < 3.9 Sufficiently low value for treatment with rapidly acting carbohydrates
Level 2 Sufficiently low value indicative of the development of severe,
Clinically significant hypoglycemia < 3.0 clinically significant complications of hypoglycemia
Level 3 there is no specific thres- Severe accident accompanied by a change in mental and/or
Severe hypoglycemia hold; usually < 2.3 somatic status and requiring treatment for recovery

72 DOI: 10.5937/Galmed2409080D