Diabetes Flashcards
threshold to start insulin in critically ill pts
180
for pts on insulin, target sugar goal is
140-180
pre meal and random goal for pts not critically ill
pre-meal < 140
random < 180
PO agent that can be used in acute illness/hospitalization
-glitazone
how does renal failure impact inpatient hypoglycemia
leads to dec insulin clearance and dec gluconeogenesis –> both inc risk of low sugars
how to adjust insulin dose based on gfr
GFR > 30 … no change
GFR 15-29… dec by 30% (give 70%)
GFR < 15 or pt on dialysis…cut in half
how do glucocorticoids effect fasting sugars
inc hepatic gluconeogenesis gives inc fasting glucose
how do glucocorticoids effect post-prandial sugars
dec glucose uptake in adipose leads to inc post-prandial sugars
what is main effect of glucocorticoids on glucose control
post-prandial effect leads to inc sugars during day
what procedure/surgery requires most peri-operative insulin
CABG
for post-op pt with A1c of 6.8 who was on NPH insulin, keep this regimen or switch to basal-bolus?
switch to basal-bolus
if pts on tube feeds, how often do u check sugars? what do you do for insulin?
check sugars q6hrs
basal insulin only
insulin to carb ratio for clear liquid diet or tube feeds
1 unit insulin for 15 grams carbs
if pt was on tube feeds and they are stopped what do you do regarding sugar management?
give IV fluids that have same amount of glucose
acid base status for dka
anion gap metabolic acidosis, ph < 7.3, bicarb < 15, ketones present
acid base status for hyperosmolar hyperglycemic non-ketosis
pH > 7.3, bicarb > 15, hyperosmolarity > 320 Osm
sugar levels for DKA vs HHS
> 450 for DKA
> 900 for HHS
tx of DKA
insulin, IV fluids, potassium
tx of HHS
low-dose insulin, aggressive IV fluids
sxs of DKA
altered mental status, kussmaul respirations, fruity odor breath
dehydration is seen in dka or hhs
BOTH but HHS more
infection can cause dka or hhs?
dka
if you just give insulin to pt in DKA, can have
low sugars
low K
low phos
what to give a pt in dka
insulin
glucose 5-10g/hr
20 mEq K+
insulin administration for DKA
initial IV bolus of 0.1 unit/kg then insulin drip at 0.1 unit/kg/hr
if sugars dont dec after 1 hr of insulin for DKA pt…then?
re-bolus, increase rate by 50% of initial dose
IV fluids for DKA tx
Normal saline if normal cardiac fxn (otherwise 1/2 NS)
if pt is not oliguric, how much K given for DKA pt?
added to IV at 40mEq/L
when do you switch to D5NS for DKA tx?
when sugars < 200
when do you switch to subq insulin for DKA tx?
after 12-16 hrs
insulin functions
- vasodilation
- metabolic modulation
- inc cell survival
- restrain platelets
- promote fibrinolysis
- enhance granulocyte fxn
- potent anti-inflammatory
do you give insulin to pts in ICU who aren’t eating/not eating much?
yes - give continuous IV insulin
how to go from IV insulin to subq - conversion factor
multiply last drip dose x 20 (this is how much glargine to give). turn off IV drip 2 hrs later
basal bolus split
50% basal
50% bolus (divided by 3 meals)
how to calculate total daily dose of insulin
pt’s weight:
x .4 for type 1 DM
x .6 for new onset or lean type 2 DM
x .8 for type 2 DM
in pts on glucocorticoids - basal bolus split?
more than 50% can be given as bolus
for short acting glucocorticoids, which insulin to give?
can consider NPH instead of glargine
if pt on continuous tube feed and glucose less than 120, how do you adjust insulin dosing?
dec by 10%
if pt on continuous tube feed and glucose less than 80, how do you adjust insulin dosing?
dec by 20%
how to calculate total daily dose of insulin if on tube feeds
pt’s weight:
x .5 for type 1 DM
x .8 for new onset or lean type 2 DM
x 1 for type 2 DM
in pt with tube feeds, how do you adjust basal to account for previous day’s correction factor?
add the basal to the amount of correction given and make that the new basal
how do you adjust basal-bolus to account for previous day’s correction factor
half of correction factor is added to give new basal value and the other half is split up into the TID prandial bolus
what med would you start in a diabetic pt to improve creatinine clearance and decrease proteinuria?
ACEI
hypothermia in a diabetic pt can suggest?
hypothyroidism
sepsis
type 1 DM and hyperinsulinemia both lead to inc risk of
coronary dz
