Diabetes/DKA/hypoglycemia Flashcards
Type 1 diabetes affects which species?
Dogs
Insulin-dependent
Type 2 diabetes affects which species?
Cats
Non-insulin dependent.
May spontaneously become non-diabetic.
What are the causes of secondary diabetes?
Pancreatic diz Hormonal Drug-induced Insulin receptor abnormalities Specific genetic syndromes
Insulin doses in intact dogs will be _______ due to hormonal influence.
Increased.
Recc. OVH after diagnosis to allow for better glucose management.
S/S of DM
PU/PD, wt loss.
Sick patients: dehydration, depression, anorexia, tachypnea, vomiting.
Dx of DM is made based off what clinical criteria?
Persisting hyperglycemia, with glucosuria.
Types of intermediate acting insulins
Vetsulin
NPH (dogs)
Humalin N
How frequently should intermediate and long acting insulin be given?
Maintenance dose given SQ, divided into BID dose.
Begin at 0.5 U/kg (daily)
Types of ultra long acting insulins:
PZI (cats)
Protamine zine and iletin.
Fructosamine testing can tell you what?
Give you an idea of the average BG over the last 1-3 weeks.
Pitfall is that patient could be relatively hyperglycemia half the time and hypo glycemia the other half and fructosamine would fall in well regulated range. Should still do blood glucose curves on patients having issues.
Common causes of insulin resistance in dogs:
estrus and diestrus progestagen Rx acromegaly hypercortisolism bacterial infection
Criteria to dx DKA:
hyperglycemia, glucosuria, and ketones in urine (+/- serum ketones - only because will show up in urine 1st).
Common blood work changes in DKA patients
KETONES…
+/-: ^ALT, ALP, Chol.
Potassium can be inc, dec, or normal. Other electrolytes may be low.
Azotemia, d/t to dehydration or renal failure. Urine should be cultured as UTI can lead to DKA in diabetics.
Goals of DKA treatment
Correct dehydration
Correct acidosis (reducing ketone bodies)
Restore normal lytes
What type of fluids should be used in initial stabilization of DKA patient?
Insulin?
Isotonic fluids
Regular insulin, b/c of it’s rapid onset and short duration.
Regular insulin (Humulin-R) characteristics
Can be given any route. Onset 30m-1h. Peak effect 3-6hr Duration 6-10h *Initial dose is 0.5 U/kg
Regular insulin via the SQ route in DKA patients.
Begin @ 0.5 U/kg Patient should not be severely hypovolemic. Titrate appropriately. Will deter ketogenesis. Glucose will decline before ketones do.
Regular insulin via the IV route in DKA patients:
Begin CRI at 0.1 U/kg/hr.
Reduce to 0.05 U/kg when BG is 250 or less.
Close monitoring essential. Potassium should be supplemented in most cases of DKA because as insulin is given and glucose is driven intracellularly, potassium follows.
Why do you want to avoid correcting hyperglycemia too quickly?
Avoid cerebral osmotic dysequilibrium.
When managing a DKA patient, when should you begin to supplement dextrose?
When the BG is in the 200-250 range you should start supplementing with 2.5-5% dextrose.
Rate of BG decline should not exceed 75-100 mg/dl/hr.
Causes of hypokalemia during DKA treatment?
Dilution
Renal tubular losses
GI losses w/ vomiting
Cellular influx of K+ (cause by acidosis correction and insulin)
Protocol for potassium supplementation:
Mild hypokal (3-3.5) - give 30mEq KCl per liter
Moderate (2.5-3) - 40 mEq KCl/L
Severe (<2.5) - 60 mEq KCl/L.
NOTE max infusion rate is 0.5-1.5 mEq/kg/hr.
When should sodium bicarb be used in DKA patients?
When pH <7.1 and patient is critical….. Dr. S’s rule is if the patient can stand he trys to avoid giving.
When to treat hypophosphatemia?
When serum P <2.0 mg/dl.
Use KPhos. Replenish at 0.06-0.18 mM/kg given over 6 hours. Discontinue when Phos reaches 2 to avoid calcium binding.
Pathogenesis of hyperosmolar nonketotic DM:
Insulinized liver deters ketone production. Peripheral insulin depletion = decreased glucose utilization.
Enhanced gluconeogenesis.
NKHDS features:
Extreme dehydration. Brain dysfunction. Marked hyperglycemia. Absent ketones. Decreased renal function. BG is often above 1000!
How do you calculate serum osmolarity?
2(Na + K) + Glu/18 + BUN/2.8
Normal: 290-310 mosm/kg
Treatment of NKHDS
0.9% NaCl if hypotensive.
0.45% NaCl, if normotensive.
Regular insulin - CRI at 0.1 U/kg/hr.
KCL
What is the definition of hypoglycemia?
<70 mg/dl.
Signs usually don’t occur until <50.
Common causes of hypoglcemia:
Insulinoma Extrapancreatic tumors Addison's Liver disease Sepsis *Insulin O.D. (most common) Starvation in young.
S/S of hypoglycemia
Anxiety Tachycardia Bizarre behavior Weakness and ataxia Muscle twitching Dementia Seizures
Tx for insulin OD
Glucose 0.5 g/kg
Karo syrup PO.
Dextrose 50% (0.5g/ml) @ 1g/kg IV.
Glucagon - 0.25-1mg IM or 0.03 IV
Insulinoma info
Beta cell adenocarcinoma most common in dogs. Prognosis is guarded.
Middle and older aged animals.
No breed predilection.
Dx of insulinoma
Inappropriate hyperinsulinemia. Concomitant hypoglycemia. Use amended insulin - glucose ratio: I/G = (Insulin u U/ml x 100)/(BG -30). >50 suggests insulinoma when expected s/s present.
Medical Tx for insulinoma:
Frequent feeding
Diazoxide
Prednisone
Many other drugs to treat symptoms.
What is the most common site for metastasis of insulinomas?
Liver
Hypoglycemia in sepsis, mechanism?
Gram - bacteria and endotoxins.
- inhibits gluconeogenesis.
- hepatic glycogen depletion
- shift to anaerobic metabolism.
