Diabetes and Insulin Flashcards
What substance is released from the intestine in response to eating that goes up to brain and provides satiety?
GLP-1 (Glucagon Like Peptide
What substance sends signals to pancreas that starts the release of insulin in response to elevated glucose after eating?
GLP-1
What cells in the pancreas release insulin?
Beta islet cells
GLP cause the liver to slow down ____ and start storing ____
- gluconeogenesis
- glycogen
3 P’s of DM
- Polydyspia
- Polyuria
- Polyphagia
Difference in body habitus b/w DM I and DM II
DM I are thin, DM II are obese
DM Type I is a genetically predisposed disease that causes an alteration on which chromosome?
Altered Human Lymphocyte Antigen on the short arm of chromosome 6
At time of diagnoses of DM type II, ___% of beta islet cells are destroyed
90%
What meds can induced hyperglycemia?
- Glucocorticoids (Long term prednisone)
- Antipsychotics (esp Risperadal, Haldol, Zyprexa)
- HIV medications
- Octreotide
What 3 conditions can cause stress-induced hyperglycemia
- Illness
- Trauma
- Pregnancy
All increase release of epi and cortisol
What two ways is DM diagnosed?
- Fasting BG > 126 x 2 occasions
- Random BG > 200mg/dl
4 ways glucose is monitored
- Blood Glucose (BG) Monitor
- Blood or Plasma Glucose
- Glycosylated Hgb (HgA1C)
- Urinary Ketones
For BG monitoring levels <75 mg/dl, a meter should read within ___ mg/dl
15
For BG monitoring levels >70 mg/dl, a meter should read within ___%
20%
What is the advantage and disadvantage of blood plasma glucose levels?
- more accurate
- takes longer and requires more blood
Normal HgA1C?
4-6%
ADA recommended HgA1C level?
<7-8.5% (depends on age of diabetic patient)
HgA1C provides a average reading based on BG over the past __ months
3
What happens if you aggressively try to drive down BG levels?
PONV, feel worse after
outcomes will be actually worse
BG level of ___ is ok to go to OR and under ___ for most procedures
175 180
T/F Only Type II DM will show urinary ketones
FALSE only type I
Type II DM will start on oral hyperglycemic meds, but most will require insulin esp if their first HgA1C is > __
10
Pro-insulin (storage) molecule is small amino acids chained together with cleavages between ___ and ___
31-32 and 64-65
What type of reaction takes place after insulin bind to alpha and beta receptors?
Phosphorylates, and then different types of cascades begin
Besides glucose, What substances are pulled into the cell by insulin through the GLUT-4 molecule?
Amino acids Phosphate Potassium Magnesium
What insulin-stimulated intracellular pathway causes cell growth, proliferation, and gene expression?
MAP Kinase signaling pathway
What insulin-stimulated intracellular pathway causes synthesis of lipids, proteins, glcogen, along with cell survival/proliferation and GLTU-4 molecule activation?
PI-3K signaling pathway
To prevent refeeding syndrome, what % of normal caloric intake should they start at
25%
Too much results in massive release of insulin, leads to massive drops in phos, K, mag –> arrhythmias, respiratory failure, death
MOA of insulin
- Binds to plasma membrane insulin receptors
- Phosphorylated receptor substrates then activate or inactivate numerous enzymes and other mediating molecules.
- Translocation of glucose transporters (GLUT’s) to plasma membranes
What do Glucose transport molecules (GLUT-4) do?
- Facilitate glucose diffusion into cells
- Shift intracellular glucose metabolism toward storage (Glycogenesis)
- Stimulate cellular uptake of amino acids, phosphate, potassium and magnesium
When does insulin resistance occur?
Occurs when there is an impaired intracellular insulin signal that results in decreased recruitment of glucose transport proteins to the plasma membrane and subsequent decrease glucose uptake.
What is the body’s response to insulin resistance ?
Compensatory hyperinsulinemia
T/F Insulin can regulate the population of receptors
True
What is the relationship between insulin and the number of insulin receptors
Inversely related
The more circulating insulin, the less number of insulin receptors on the cell
What is the t1/2 of IV insulin?
5-10 mins but the duration of effect is longer
What is the DOA of insulin?
30-90 mins
Where is insulin metabolized?
liver and kidneys
How much insulin that reaches the liver is metabolized on a single pass?
50%
What prolongs the half life of insulin more, liver or renal disease?
Renal disease
Insulin administered SQ is released ____ into the circulation
slowly
Basal rate of insulin secretion by the pancreas is _ unit/hr.
1
Food prompts a _ - _ fold increase in secretion
5-10x
Total daily secretion of insulin is approx. __ units/day
40
T/F Insulin response to glucose is greater for oral ingestion than for I.V. infusion
True eat a sandwich - better insulin response than glucose
What is the peak of long acting insulins?
There is no peak
Regarding insulin types, there duration of action correlates with ___
onset of action
Long acting insulins are also known as ____
glargine
What is the longest acting insulin?
Degludec (Tresiba), up to 42 hrs good for people that aren’t good at remembering to take insulin
What is the only time you would give lantus BID?
If the volume is too much to handle in one dose. Otherwise its pointless
Onset, peak, and duration of regular insulin
30mins 2-4 hrs 6-8 hrs
what is the DOA of Levemir?
6-23 hours
It’s intermediate like NPH
What types of insulin are considered “basal rate insulins”?
Long and intermediate acting (long is given once daily, intermediate BID)
In premixed insulin, which number is the longer acting one?
First number
ex. humulin 70/30 (70% is NPH, 30% is regular
T/F Insulin is one of the top 5 drugs that send people to ER
True
Whats a drawback to rapid acting insulins?
With the rapid acting - Wild swings in glucose can make people feel sick, dizzy
Newer insulin agents are produced from ___ Older agents were produced from ___
recombinant technology
animal (beef and pork)
What is the benefit of recombinant technology insulins?
Allergy or immunoresistance that could accompany administration of animal insulins is no longer a significant problem
Only ___ acting insulin may be given IV/ via pump
short
no NPH or long acting
T/F All insulins can be given SQ
True
Side effects of insulin
- Hypoglycemia
- Hypokalemia (also hypo phos and mag)
- Allergic Reactions
- Lipodystrophy
- Insulin Resistance
- Drug Interactions
What is the most severe side effect of insulin?
hypoglycemia
what is lipodystrophy?
injecting in same site over and over again results in atrophy of fat at site of SQ injection, get hard bumps.
How can lipodystrophy be minimized?
Minimized by rotating the site of injection every 3 days
Signs and symptoms of hypoglycemia
Diaphoresis Tachycardia Hypertension
Hypoglycemia symptoms reflect the compensatory effects of increased ____
epinephrine
What is Somogyi effect?
Rebound hyperglycemia caused by sympathetic nervous system activity in response to hypoglycemia may mask the correct diagnosis
What is the most significant risk factor for developing insulin resistance?
If the diabetic patient doesn’t change their lifestyle and diet
“ex. I took my insulin, so now I can eat a whole cake”
At what level would you begin to worry about hypoglycemia intra-op?
80 Diagnosis under GA is difficult
Chronic NPH administration may lead to the development of antibodies to _____
protamine
what type of currently available type of insulin is most likely to cause an allergic reaction?
NPH (due to protamine)
A patient is considered to be insulin resistant if they require > ___ units/day
100 Battling DOWN REGULATIOn of insulin receptors
Acute insulin resistance is associated with what 3 things?
trauma
surgery
infection
What meds can counter the effects of insulin?
Epinephrine
ACTH/glucocortocoids
Estrogen
Glucagon
How does epinephrine counter insulin?
- Inhibits the secretion of insulin
- Stimulates glycogenolysis
What does epinephrine stimulate ?
Glycogenolysis
With multiple SQ injection insulin management, what percent is given at intermediate or long acting? Versus how much is given in additional dosages with meals and sugar checks?
70% as intermediate or long acting at bedtime. 30% as additional doses with rapid acting
How often should insulin pump injection site be changed?
every 2-4 days
What type of insulin is typically used in insulin pumps?
Regular or Lispro
What is afreeza?
Rapid acting Inhaled Insulin with onset 10-15 min and duration 3 hours.
“a hot steaming pile of garbage” per Emily
In what situation would insulin sliding scale be used as sole treatment method?
When someone is on a steroid that is causing hyperglycemia.
Otherwise SS’s should e NOT be used alone, need some sort of basal coverage as well
What are the four main long term complications of diabetes mellitus?
- Atherosclerosis
- Neuropathy
- Nephropathy
- Retinopathy
Diabetes is the number one cause of….?
1 cause of:
- Dialysis
- Blindness
- Amputation
due to large size of a glucose molecule that destroy tiny capillaries/nephrons
What electrolyte abnormality can have an increased risk with perioperative hyperglycemia?
Hyponatremia
As glucose goes up, Na+ begins to come down
T/F: High rather than low blood glucose is desired under general anesthesia?
True; because GA can mask signs of low blood glucose
What is optimal blood glucose levels perioperatively? Total joints?
80-180mg/dl
Total joints 80-150mg/dl
What is included in “non-tight control regimen”?
1/4 to 1/2 dose intermediate or long acting prior to surgery.
Coverage based on BG concentrations.
Initiate IV insulin infusion based on continued need for correction.
1 unit of regular insulin will decrease BG by how many mg/dl?
50-60mg/dl per 1 unit regular insulin
What is included in “Tight Control regimen”?
- Maintenance D5W at 50ml/hr/70kg body weight
- Insulin at 0.05u/kg/hr (0.5-1u/hr)
- Check BG Q1-2hrs
- Adjust drip as needed to obtain targeted goal
If “tight control regimen” being used and 4 hours into a case the BG is 300mg/dl, should you bolus regular insulin?
No; bolusing regular insulin can create dangerous swings of glucose levels. Better to titrate gtt accordingly
What is perioperative management of patients with insulin pumps?
- Prior to surgery= clear liquids with or without sugar 2. Maintain basal infusion rate
- Turn off preprandial boluses
- Measure BG Q1hr
- Question patient how much insulin is typically required to decrease BG by 50mg/dl
What substance is released from the intestine in response to eating that goes up to brain and provides satiety?
GLP-1 (Glucagon Like Peptide
