Block 1 Flashcards
What is inpatient hyperglycemia?
≥140mg/dl
What are the major classes of drugs that cause hyperglycemia?
Corticosteroids
Atypical antipsychotics (Risperidone, Olanzapine, Quetiapine)
Immunosuppressants
Catecholamines
Insulin is given to those with a range of ______ to keep them off of >180mg/dl
140-180
What are the rapid acting insulins?
Aspart, Lispro, Glulisine
How do you determine the dose of insulin experienced and insulin naive patients?
Experienced = take 1/2 to 1/3 of their normal dose
Naive = 0.1u/kg/day (outpatient)
If well controlled or at higher risk of hypoglycemia = 0.2u/kg/day
If poorly controlled = 0.5-0.8u/kg
BUT naive pt use sliding scales but should remain the sole treatment
Which insulin is typically used in ICU patients?
Insulin regular IV bags
When a patient is stable, how do you transition from IV to SQ insulin?
Calculate TDD by taking average rate/hr in the past 6-8hrs
Multiply number by 24 (total IV insulin) then multiplying it by 0.8 (total SC insulin)
SC is given as 50/50 basal and bolus
When should you monitor pt on basal only insulin?
Once daily with morning labs
When should you monitor pt on basal + bolus regimen?
Before each meal and at bedtime
What is hypoglycemia?
Warnings begin at <70 but officially ≤54mg/ml
How do you manage hypoglycemia?
BG checked q15min
D50W 25ml if <70
D50W 50ml if <54
Glucagon if <70 + no IV access
Differentiating pieces of DKA and HHS?
DKA - metabolic acidosis + ketonemia; tachypnea, kussmaul breathing, acetone breath
HHS - high serum osmolality + dehydration; hypotension
How often should you monitor a DKA pt?
Every 2-4 hours
When treating DKA or HHS, what kind of insulin plan do we utilize?
Bolus 0.1u/kg
0.1u/kg/hr continuously IV infusion
DKA BG <200 or HHS BG<300; decrease dose to 0.02-0.05u/kg/hr and switch fluids to D51/2NS
What is the corrected sodium equation?
Measured Na + ((0.016*(glucose-100))
When do we correct potassium during insulin therapy?
<3.3 = hold insulin, give 20-30mEq/hr until potassium is above 3.3
3.3-5.2 = give 20-30mEq/hr in 1L fluid
> 5.2 = dont give potassium and check q2hrs
How do you measure anion gap?
Na - (Cl+HCO3)
Normal <12
How do you manage fluids in DKA/HHS?
Regardless of condition, 1L bolus of NS
If <135 Na, Give NS 250-500ml/hr
If >135 Na, Give 1/2NS 250-500ml/hr
If glucose range is below their targets, just add D5W
DKA is resolved in what criteria?
Glucose <200 and two of the following:
Bicarb≥15
Venous pH>7.3
Anion gap≤12
HHS is resolved in what criteria?
Normal osmolality and normal mental status
Post resolution care, when should you start SQ admin of insulin?
1-2 hrs before stopping IV
What are some complications of DVT and PE?
DVT = swelling and pain, unilaterally
PE = Arrhythmias and death, SOB, chest pain
RF for VTE?
Stasis
ICU
Cancer
Rx (estrogen, vasopressor, ESAs)
Patient-related
Surgery
What is a good thing about using the PADUA prediction score for VTE?
If you score low, it has a 99% value stating that you have a low risk for VTE, it is not specific nor sensitive
Which diagnostic tests are used in DVT vs PE?
DVT = compression ultrasound
PE = CT and ventilation/perfusion scans
Prophylactic dosing of:
Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)
Enoxaparin 40mg daily
Dalteparin 5000u daily
Heparin 5000u q8-12hrs
Fondaparinux 2.5mg daily
DOACs not recommended
MOA of:
Enoxaparin
Dalteparin
Unfractionated heparin
Fondaparinux (Xa inhibitor)
Enoxaparin + Dalteparin + Fondaparinux = Indirect Xa inhibitors
Heparin = indirect IIa and Xa inhibitor
Dose of heparin and lovenox in BMI>40?
Heparin 7500 TID
Lovenox 40mg BID or 0.5mg/kg/day
Dose of heparin and lovenox in low body weight <50kg
Heparin 5000 BID or TID
Lovenox 30mg QD
Dose of heparin and lovenox in renal dysfunction?
Heparin = no change
Lovenox; if CrCl<30 its 30mg QD or switch to heparin
Dose of heparin and lovenox in surgery?
Major orthopedic surgery, then Lovenox 30mg BID
What RF are there for hemorrhages?
Increasing doses of anticoagulation, concomitant antiplatelet therapy
Low body weight (<50kg)
Malignancy, HF, renal failure
h/o bleed
What is a major bleed?
Fatal bleed
Symptomatic bleed in critical organ
Bleeding causing Hgb >=2g/dl
Transfusion w/ 2+ units of blood
What is a life-threatening bleed?
Symptomatic intracranial bleed
Bleeding causing Hgb >=5g/dl
Transfusion w/ 4+ units of blood
Bleed associated w/ hypotension
What do they inactive:
Protamine
Protamine - UFH + LMWH
1mg Protamine neutralizes ____ units of UFH
100
Utilize the last _____ hours of heparin administered when using protamine
2-3