Let’s go to the third N, other complications
of diabetes mellitus.
This then brings us to neuropathy.
Couple of things that you want to keep in
The neuropathy along with the peripheral vascular
disease, meaning to say microangiopathy, so
things that you want to pay attention to for
sure before you address any type of attending
or patient or board is, is there diabetic
retinopathy manifesting, is there diabetic
nephropathy taking place, diabetic neuropathy
and diabetic microangiopathy?
Put these together, the neuropathy and microangiopathy,
put them together and the reason for that
is, let’s say what areas of the body are
you always worried about or what concerns
you with a diabetic?
It is the decubitus areas, isn’t it?
The decubitus areas, meaning to say the areas
of the body where the patient is quite dependent
maybe, well, well, I am doing quite a bit
So, therefore, my dependent area would be
my… the soles of my feet, the bottom of
If there is a diabetic who is undergoing surgery,
then please understand that if your patient
is bedridden, that the dependent areas in
that patient would be maybe perhaps the back
of that patient, right, or maybe the buttocks.
Are we clear?
In those areas because the dependent already
dependent, meaning to say that you are-you
are causing stress because of sheer gravity
that there might be decreased blood supply
along with that in the diabetic patient, there
is decreased blood supply due to peripheral
Now, when there is decrease of blood supply
taking place to that area in the skin, hmm,
what may then happen?
Necrosis is setting in, wow, and can the patient
feel the pain?
Because of neuropathy, the nerves have been
With all that said, let’s take a look.
Can be generalized focal or part of autonomic,
which we will get into in a second.
Chronic sensorimotor distal symmetric polyneuropathy,
what that basically means is that the both
distal extremities could be affected symmetrically.
Polyneuropathy, many nerves could undergo
Most common, often asymptomatic, increased
risk of foot ulcer, the dependent area, often
treated with antidepressants, tricyclics and
They seem to have some type of, perhaps if
any preservation of your nerves at times you
have learned that some of these antidepressants
could actually work; not that the patient
is depressed, it is a fact that you are using
it because you want to try to revive or preserve
some of that nerve functioning.
So, what may then happen if with the worse
case scenario, if you are worried about not
feeling the pain ulcers, at some point may
then become gangrenous and your next step
of management is you are left with no choice
but to amputate.
Continue discussing neuropathy.
Now, we’ll take a look at autonomic neuropathy.
Why does this become important, hmm?
Your patient has coronary arterial disease
with diabetes, arterial disease, arterial.
If it is the artery, then what kind of damage
is taking place in your blood vessel in diabetes?
So, now, I want you to go ahead and think
about the left anterior descending artery
or coronary artery which has undergone massive
It is getting bigger and bigger and bigger,
this atheroma is, and as a dose, so you are
going from stable to unstable angina and,
oh my goodness, the patient has elevated levels
of troponin I. Patient comes in and says,
“Doc, I am not feeling too well, get really,
really tired and fatigued, I can’t even…
can’t even really walk too much without
feeling really tired and this concerns me.”
“No, not really.”
You find troponin I’s to be elevated.
Next, you end up finding ST elevations in
V1 through V4.
Wow, this-this seems an awful lot like myocardial
infarction, but the patient is saying there
is no chest pain.
There is no radiation of the pain up into
the jaw and into the shoulder.
What is going on?
A silent myocardial infarction, hmm, a silent
So, with diabetic neuropathy, the fact that
if it is a cardiovascular system, what should
normally be feeling the pain and such is not
Keep that in mind.
Next, orthostatic hypotension, autonomic
nervous system, the cardiovascular system,
you are going from supine to erect position;
I will first walk you through the physio.
Supine sleeping to erect position, maybe suddenly
sitting up or perhaps even standing up suddenly,
all the blood then rushes down to the lower
You with me?
With that blood dropping down to lower extremity,
you can expect that the blood pressure or
the profusion through the carotids and the
aortic arch is not as it what it-what it should
be because it’s now moved to the gravitational
dependent areas, right?
Who senses this in the carotids especially?
In the carotid sinus baroreceptors sense this.
Do you remember now?
Let me ask you anatomically.
The carotid sinus communicates with the medulla
through which cranial nerve?
Good, why did I-why did I pick the carotid
Because that of the two locations of baroreceptor,
meaning to say either carotid sinus, aortic
arch, the carotid sinus becomes much, much,
much, much more sensitive and it communicates
efferently with the sympathetic nervous system
or with the autonomic nervous system via glossopharyngeal,
right, 9th cranial nerve.
Next, what should happen?
You should have sympathetic outflow so that
you can then preserve or restore the blood
pressure vasoconstrict so that you can then
have proper preservation of your blood pressure.
That isn’t happening.
Here, autonomic nervous system has been knocked
Because of neuropathy, why?
Because of diabetes mellitus.
So, therefore, from going from supine to erect
position, you remain hypotensive, this is
called orthostatic hypotension.
High mortality, you are worried.
Move on, the gastrointestinal system, you
have heard of the enteric nervous system,
you have heard of resting digest, you have
heard of parasympathetic nervous system responsible
for proper movement.
Those are part of nerves, aren’t they?
They are all nerves and so, therefore, if
you don’t have proper vagal stimuli of the
stomach then you don’t have proper propulsion,
you don’t have proper peristalsis.
So, therefore, the stomach becomes paralyzed,
what do we call this?
Gastroparalysis or gastroparesis.
So, what is your next step of management?
You want to obviously facilitate the emptying
of the stomach, so you are going to use prokinetic
drugs including metoclopramide.
In the GI, we talked about, what about the
Once again, you need proper nerve conduction
in a male to the penis, you need to make sure
that you have proper erection, ejaculation,
All of that is going to be responsible by
whom? Autonomic nervous system.
You can expect there to be erectile dysfunction,
retrograde ejaculation, and from the bladder,
you have dysfunction.
You need the parasympathetic so that you contract
the detrusor muscle, relax your sphincter
so that you can then allow for urination,
that may all be disrupted when you have diabetic
Welcome to autonomic neuropathy with diabetes.
This is a picture in which we have the dependent
area of a- of the foot symmetrically, we call
this stocking glove, stocking glove type of
issue in which along with peripheral vascular
disease in which there is decrease of blood
supply to the lower extremity, the dependent
area resulting in erosion, necrosis, ulceration
and worst case scenario, there might be gangrene.
You ask the patient did you feel the pain
or do you feel any pain?
Diabetic neuropathy, extremely important,
make sure that you always check the dependent
areas in a patient with diabetes.
Chances are pretty good that you are going
to end up finding an ulcer and when you do
so, you do everything in power to properly
address it, bandage it and you clean it up
constantly, you do not just let it go because
otherwise it will get infected, there isn’t
proper blood supply, you can’t deliver,
there will be seasons such to clean up the
debris, that is not good, this is not good.
Cardiovascular disease and diabetes, arthrosclerosis,
these are the arteries.
Take a look at the mortality, 80 percent,
coronary arterial disease, myocardial infarction,
cerebral vascular… cerebral vascular disease,
stroke, peripheral vascular disease, you have
heard of claudication and worst case scenario,
I just walked you through ulcers and gangrene.
Myocardial ischemia may be silent, why is
I gave you a patient who walked in and she
told you that feeling really tired and fatigued,
you find troponin I, but there was no chest
pain, silent myocardial infarction due to
Peripheral arterial disease may result in
claudication and what does that mean to you?
It means that there is pain in the lower legs
or the thighs because of decrease of blood
supply so kind of think of this as being angina
of your leg, non healing ulcers.
Once again, all part of peripheral arterial
disease because you don’t have proper blood
supply to the tissue.
Annual screening for sure for hyperlipidemia
and hypertension, you need to be aggressive.
Remember that the goal for blood pressure
is keep it less than 130/80, that’s ideal.
Now, obviously that is not going to be practical
in many instances, but that is your ideal
Your LDL goal, you want this to be less than
In a diabetic, you need to be extremely, extremely
LDL contains cholesterol, you want that to