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Diabetic Emergencies Flashcards

1
Q

Consequences of diabetic emergencies

A

Blindness
Renal failure
Amputation
Heart disease (basically inevitable)
Stroke

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2
Q

What does being Hyperglycemic for long periods of time increase risks of? why?

A

Infection
MI
PE
CVA
DVT

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3
Q

Bodily functions that happen when someone is Hyperglycemic for long periods of time

A

Clotting
Vasoconstriction
Impaired gastric motility
Decreased respiratory muscle function

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4
Q

*Target goals of blood sugar for patient with hyperglycemia in ICU

A

Initially: less than or equal to 180
Then *140-180

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5
Q

Why aren’t targets of less than or equal to 110 recommended?

A

May be associated with increased mortality

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6
Q

What is glucose metabolism regulated by?

A

Regulated by the liver

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7
Q

How does the liver regulate glucose metabolism?

A

Liver stores and synthesizes glucose (stored as glycogen)

Liver releases glucose when BS decreases
Liver stores glucose when BS increases

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8
Q

How is glucose stored?

A

In the liver as glycogen
In skeletal muscle as glycogen
In fat cells as triglycerides

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9
Q

What does insulin stimulate?

A

Glucose uptake by cells
Synthesis of glycogen
Synthesis off protein and amino acids
Transport of amino acids and fatty acids into cells
Conversion of fatty acids to triglycerides

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10
Q

What does insulin inhibit?

A

Glucose production (by glycogenolysis and glyconeogenesis)
Lipolysis
Protein catabolism

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11
Q

What is glycogenolysis?

A

Breakdown of glycogen into glucose to be used

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12
Q

What is gluconeogenesis?

A

Production of glucose from proteins/fat

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13
Q

What is the body’s physiologic response to insufficient insulin?

A

Decreased glycogenesis (glucose stays in bloodstream)
Increased glycogenolysis (but not enough insulin to actually use, so it stays in blood)
Increased gluconeogenesis
Decreased glycolysis
Increased Lipolysis

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14
Q

What is glycolysis?

A

Breakdown of glucose to CO2 and H2O

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15
Q

What is Lipolysis?

A

Breakdown of fats to ketones, an alternative energy source

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16
Q

What are the 5 counterregulatory hormones?

A

Glucagon
Epinephrine
Cortisol
Norepinephrine
Growth hormone

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17
Q

*What do the counterregulatory hormones do?

A

*Increase blood glucose

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18
Q

What causes a Hyperglycemic crisis (DKA or HHS)?

A

Result from reduction in net effect of circulating insulin
Coupled with simultaneous elevation of counter-regulatory hormones
Results in hepatic and renal glucose production and decreased use of glucose in peripheral tissues

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19
Q

*Common factors leading to DKA/HHS

A

Omission of adequate treatment of DM
New-onset DM
Infection
Pre-existing illness
Acute illness
Stress
Other endocrine disorders
High-calorie parenteral/enteral nutrition

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20
Q

Description of DKA

A

Acute complication of DM
Associated with insulin deficiency, coupled with simultaneous increase in counterregulatory hormones

*Results in hyperglycemia, dehydration, electrolyte depletion, and ketones

*Develops quickly

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21
Q

S/S of DKA

A

Hyperglycemia
Dehydration
Electrolyte depletion
Ketosis

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22
Q

Contributing factors of DKA

A

Insulin pump malfunction
Insulin pump infusion set/site issues
Increased insulin need

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23
Q

What could be the causes of insulin pump infusion set/site issues?

A

Infection
Disconnection
Catheter kink/migration

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24
Q

What could cause increased insulin need?

A

Insulin resistance due to:
Pregnancy
Puberty
Before menstruation

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25
Clinical manifestations of DKA
Classic S/S: Polyuria, polydipsia, polyphagia, hot dry skin Cardiovascular: Dehydration, electrolyte imbalances, Tachycardia, hypotension, Weak, thready pulse GI: Anorexia, nausea, vomiting, abdominal pain, weight loss (r/t decreased blood volume from loss of fluid) Neuro: Lethargy, fatigue, altered LOC Respiratory: Fruity breath, Kussmaul respirations
26
*Blood glucose measurement for DKA
>250mg/dL (but often much higher: average = 675)
27
Ketone findings for DKA
Positive serum and urine ketones
28
PH for DKA
<7.30
29
*HCO3 for DKA
<15 mEq/L
30
Sodium for DKA
May be normal, low, or high
31
*Potassium for DKA
May initially be normal, then high, then low (low b/c insulin also causes potassium to go into cells) *regardless of what serum potassium says, there is always a total body potassium defecit
32
BUN and creatinine for DKA
BUN >20mg/dL Cr >1.5 mg/dL
33
Serum osmolality for DKA
Avg 330 mOsmkg (*measures concentration: higher = more dehydrated)
34
Order of interventions to manage DKA
Correct volume depletion Correct hyperglycemia Correct electrolyte imbalances
35
*What type of insulin is used to correct hyperglycemia emergencies?
Short acting aka regular insulin
36
Description of HHS
Hyperosmolar, hyperglycemic state resulting from inadequate insulin secretion *without significant ketosis Higher than average BG and higher osmolality *Insidious onset May be more severe than DKA
37
Patients HHS are more common in
Type 2 DM and elderly
38
Possible causes of HHS
*Dehydration (diuretics & not replacing fluids, decreased thirst) *Stressed induced (MI, CVA, infection) Enteral/parenteral nutrition MI, CVA Glucocorticoids (for long periods) Other drugs
39
Clinical manifestations of HHS
Dry skin & mucous membranes Extreme thirst (OA may not) Extreme dehydration (Hypotensive, tachycardia) Neuro: Generalized focal seizures, Reversible hemiparesis, Confusion, Possible coma
40
*BG for HHS
>1000 mg/dL
41
*Osmolality for HHS
> 350 mOsm/L
42
pH for HHS
>7.30
43
HCO3 for HHS
>15 mEq/L
44
Ketones for HHS
Negative serum and urine ketones
45
Sodium for HHS
Varies related to hydration
46
Potassium for HHS
Varies related to hydration
47
BUN and creatinine for HHS
Elevated
48
Goal for HHS management
To complete rehydration and normalize BG in 24-48 hours
49
*Guidelines to treat HHS and DKA
*Replace half of estimated fluid deficit in 8 hours *Replace remainder in next 16 hours
50
Which patients do we need to be even more careful with when replacing fluids?
Patients prone to pulmonary edema, such as pts with renal failure or heart failure Older adults Need more frequent monitoring during first hour
51
*Exact guidelines for treating patients with fluid volume deficit related to osmotic diuresis secondary to hyperglycemia (Which type of fluid to use when)
1 - Infuse NS 1 liter over first hour (999 mL/hr) as long as pt can tolerate 2 - Change to .45% NS when Na is normal or increased 3 - When BG reaches about 200 mg/dL, D5&1/2NS to prevent hypoglycemia
52
When treating FVD in hyperglycemia, what should fluids do you give after the NS for the first hour?
- Then 10-15 mL/kg/hr if not shocky (monitor VS, LOC, CVP, PAP, I&O qh) - If shocky, 20 mL/kg/hr. Once stable, 7.5 mL/kg/hr - Monitor for overload (crackles, decreased LOC, increased BP)
53
How do you determine if a patient is not tolerating fluids?
S/S Regain then lose consciousness Hearing crackles Bounding pulses New onset of high hypertension
54
Which electrolytes may need to be replaced after managing FVD in hyperglycemic patients?
K Phos Mg Cl
55
*Symptoms of hypokalemia
Muscle weakness Cramps Abdominal distention Hypotension Weak pulses Broad flat T waves U wave visible PVB’s (heart muscle not right, ventricles over compensating)
56
When does insulin and monitoring of ventricles begin?
After: 1 - 1st liter of IVF 2 - K > 3.3 mEq/L (20-30 mEq of K added to IVF) 3 - Pt is producing urine
57
*What is the goal for reducing blood glucose?
Reduce by 50-75 mg/dL/hr
58
After treating a DKA patient for FVD, how do you begin treatment with insulin? What is the goal?
1st: loading dose of regular insulin (0.1 u/kg of ideal body weight) 2nd: regular insulin infusion at 0.1 u/kg/h until pH>7.3 and HCO3 >15 mEq/L Monitor BG hourly Pt usually NPO
59
For a DKA patient, when pH and HCO3 goals are reached, what should you decrease insulin by? And what is the target?
3rd: decrease by 0.05 u/kg/hr with target of 100-150 mg/dL until acidosis is resolved Monitor BG hourly Pt usually NPO
60
Next steps after acidosis is resolved in a patient with DKA and glucose goal is reached:
SC insulin 1-2 hrs prior to discontinuation of infusion, when BG < or = to 200 mg/dL and 2 of the following are met: Venous pH >7.3 HCO3 > 15 mEq/L Anion gap > or + 12 mEq/L
61
Once glucose goal is reached and pt’s infusion is ready to be discontinued, how often should BG be monitored?
Every 6-8 hours
62
When should acidosis be treated with bicarb?
If HCO3 is < 7 or pH is <7
63
For a HHS patient, when pH and HCO3 goals are reached, what should you decrease insulin by? And what is the target?
Decrease by 0.2-0.5 u/kg/hr when BG 300 mg/dL With target 200-300 mg/dL
64
When should HHS patients be transitioned to SC insulin?
When mental status improves
65
Why are the guidelines different for decreasing insulin and goal BS different between DKA and HHS patients?
Blood sugar is usually higher in HHS patients and these patients are usually more dehydrated So their symptoms will be fixed faster because of this
66
Education for patient and family after hyperglycemic crisis:
Education to prevent future episodes: Hydration Reporting illness Reporting BS >250 Reporting inability to keep food or fluids down Sick day rules Monitoring A1C levels
67
*Description of hypoglycemia
Acute condition in which relative or absolute *excess of insulin results in *BG < 70 mg/dL
68
Causes of hypoglycemia
Too much exogenous insulin Inappropriate site rotation Absorption variability Gastroparesis (delayed emptying) Inadequate intake Increased energy requirements Impaired counterregulation (don’t have those 5 hormones) Hypoglycemic unawareness
69
5 hormones involved in hypoglycemia
Glucagon Epinephrine Cortisol Norepinephrine Growth hormone (Glucose usage is inhibited in peripheral tissues by epi, cortisol, GH)
70
Symptoms of mild hypoglycemia And BG level
Patient completely alert Pallor Diaphoresis Tachycardia Palpitations Hunger or shakiness BG < 51-70 Patient is able to drink
71
Treatment of mild hypoglycemia
10-15g of glucose (carbohydrate) by mouth
72
Symptoms of moderate hypoglycemia And BG level
Patient is conscious, cooperative, and able to swallow safely Difficulty concentrating Confusion Slurred speech Extreme fatigue BG < 55 mg/dL Patient is able to drink
73
Treatment for moderate hypoglycemia
20-30 g of glucose (carbohydrate) by mouth
74
Symptoms of severe hypoglycemia And BG level
Patient is uncooperative or unconscious BG < 54 mg/dL or patient is unable to drink
75
Treatment for severe hypoglycemia
With IV access: 50 mL 50% dextrose in water solution (D50W) Without IV access: 0.5-1 mg glucagon SQ, IV, IM and turn pt on side or observe to avoid potential aspiration from nausea and vomiting side effect
76
Education for pt and family regarding hypoglycemia
Prevention of future episodes: Teach common causes Do not change brands of insulin S/S hypoglycemia Medic alert bracelet Self BG monitoring Keep available source of CHO on person at all times Identifying cause of episode

Critical Care (35 decks)

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