Diabetes

Question 1

What is a key difference in pathology of Type 1 and Type 2 Diabetes?

Answer 1

Type 1 is strongly a/w presence of human leukocyte antigens and Islet cell antibodies are found in apps 90% of patients.
Type 2 is caused by either tissue insensitivity to insulin or insulin secretory defect and is NOT linked to human leukocyte antigens or islet cell antibodies. Circulating insulin exists enough to prevent ketoacidosis but is inadequate to meet patients insulin needs

Question 2

what is Type 2 DM associated with

Answer 2

Syndrome X: obesity, HTN, abnormal lipid profiles
Metabolic Syndrome: waist circumference greater than 40 or 35 for women.
Bp greater than 130/85
Triglycerides > 150
FBG > 100
HDL < 40 or < 50 in women

Question 3

what is often the first symptom of type 2 DM in women?

Answer 3

recurrent vaginitis

Question 4

Labs and Diagnostics for DM

Answer 4

random plasma glucose > 200 with polyuria, polydipsia and weight loss (type 1)
serum fasting bs > 126 on 2 occasions
ketonemia or ketonuria (type 1 only)
bun/crt elevated
hub a1c normal 5.5-7%
Impaired glucose tolerance: FBG > 100 and < 125

Question 5

Dosing of insulin therapy in Type 1 Diabetics

Answer 5

begin with 0.5u/kg/day: 2/3 morning and 1/3 in evening

Question 6

What is the somogyi effect

Answer 6

Nocturnal hypoglycemia develops stimulating a surge of counter regulatory hormones (somogyi effect) which raise blood sugar. Pt will be hypoglycemic at 0300 but then hyperglycemic at 0700>
what to do: reduce or omit the bedtime dose of insulin

Question 7

Dawn Phenomenon

Answer 7

Tissue becomes desensitized to insulin nocturnally. BG becomes progressively elevated throughout the night resulting in elevated BG levels in am.
what to do:add or increase the at- bedtime dose of insulin

Question 8

What is the pathology of DKA

Answer 8

Intracellular dehydration as a result of elevated blood glucose levels

Question 9

what is the pathology of HHNK

Answer 9

Intracellular dehydration as result of greatly elevated sugars
cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion

Question 10

Labs and Diagnostics of DKA

Answer 10

hyperglycemia > 250
ketonemia/uria
glycosuria
acidosis (ph , 7.3)-metabolic
loc HCO3
low pCO2
elevated hct, bun/crt
hyperkalemia
leukocytosis
hyperosmolality

Question 11

labs and diagnostics of HHNK

Answer 11

bs > 600
hyperosmolality (> 310 mOsm/L)
elevated Bun/crt
elevated hgb a1c
normal pH
normal anion gap

Question 12

1st step in management of DKA

Answer 12

protect airway
administer o2
isotonic fluids (NS) at least 1 liter in first hour then 500 ml/hr. If BG > 500 use 1/2 NS after 1st hour (as water deficit exceeds sodium loss)
when glucose falls to < 250 change to D5 1/2 NS to prevent hypoglycemia
0.1u/kg regular insulin IV bolus followed by 0.1 u/kg/hr. If glucose does not fall by at least 10% after first hour then repeat bolus

Question 13

what to do to correct severe acidosis (pH < 7.1)

Answer 13

add bicarb drip (44-48mEq in 900 ml 1/2 NS until pH reaches > 7.1

Question 14

DKA: what to do with Potassium

Answer 14

do not treat initial hyperkalemia
hourly urinary output
will eventually probably need to switch to Kcl infusion to prevent hypokalemia

Question 15

HHNK management first step

Answer 15

1) NS (6-10 liters)
2) once serum Na reaches 145 change to 1/2 NS (expect 4-6 liters in first 8-10 hours of therapy)
3) D5 1/2 NS

Question 16

HHNK: when plasma glucose reaches 250:

Answer 16

add D5 to the solution
15 U regular insulin IV followed by 10-15 U SQ (immediately)
additional insulin may not be necessary

Question 17

what happens when pH goes down

Answer 17

K goes up

Question 18

Mngt DKA

Answer 18

3 volume resuscitation
1) isotonic fluid (NS or ringer's)
2) more hemodynamically stable tx problem (intracellular dehydration) so use fluid that hydrates the cell: hypotonic solutions (1/2 NS)
3) as glucose drops add D5 to 1/2 NS
insulin drip warranted as well