DM 1 (two) Flashcards
What tx for DM1?
- Used for primary prevention
- Pts w/ incr. risk of CVD
- F: >50
- M: >60
- and 1 RF: HTN, HLD, smoking, fam hx of premature dz, albumineria
Acetylsalicylic acid
Pts w/ Type 1 DM can get what 2 transplants?
Which one can they NOT get?
- Pancreas transplantation with or without kidney transplantation
- Islet cell transplant
- NOT: pancreatic islet auto-transplantation
Type 1 or 2 DM?
- Moderately deficient control of hyperglycemia
- SLIGHT elevation of LDL cholesterol
- Slight elevation of serum triglycerides
- Little/if any change to HDL
- Once hyperglycemia is corrected, –> lipoprotein levels are normal
Type 1
Type 1 or 2 DM?
- “Diabetic Dyslipidemia” is characteristic of insulin resistance syndrome
- HIGH serum triglyceride level >300
- LOW HDL cholesterol <30
- Qualitative change in LDL particles, smaller/dense LDL particles are more susceptible to oxidation, renders them more atherogenic.
Type 2
What are the 2 neuro/vascular dz complications of diabetes?
- Diabetic foot ulcers
- Gangrene of feet
What are the 4 heart disease complications?
- Coronary atherosclerosis
- Myocardial infarction
- Peripheral vascular disease
- Stroke
What are the 3 causes of Hypoglycemia?
- Behavioral
- Regulatory issues
- Diabetic complications
What are the 3 behavioral causes of Hypoglycemia?
- Too much insulin
- Too much ETOH
- Post-exercise
What are the 2 causes of regulatory issues leading to Hypoglycemia?
- Loss of glucagon response
- Sympatho-adrenal responses
What are the 2 diabetic complications leading to Hypoglycemia?
- Gastroparesis
- End-stage kidney disease
Sxs of what?
- Shaky
- Tachy
- Diaphoretic
- Dizzy
- Anxious
- Hungry
- Blurred vision
- Weak/tired
- HA
- Nervous/upset
Hypoglycemia
What meds can induce Hypoglycemia?
◦Sulfonylureas
◦Gatifloxacin & levofloxacin
◦ACE inhibitors
◦Salicylates
◦β-adrenergic blocking agents
◦Quinine
Pentamidine
What can these lead to?
- Hypopituitarism
- Addison disease, or myxedema
- Disorders related to liver malfunction, such as acute alcoholism (glycogen depletion) or liver failure
- Gastrointestinal surgery
- Insulinoma
Hypoglycemia
What are the 4 ways to prevent/tx hypoglycemia?
- Glucose tablets or Juice
- 15 g of carbs
- Parenteral glucagon emergency kit (1 mg)
- 50 mL of 50% glucose solution by rapid IV infusion
What is this effect called?
- Nocturnal hypoglycemia –> leads to surge of counter-regulatory hormones to produce high blood glucose by 7 AM (pre-breakfast hyperglycemia)
- How is it treated?
- Somogyi Effect
-
Tx:
- Eliminating dose of intermediate insulin at dinner time
- Giving intermiediate insulin at a lower dose at bedtime
- Increase food intake at bed time
- Glucose >600
- Osmolarity >320 (normal is 280-295)
- Due to ETOH, antifreeze
- No ion gap (normal)
HHS
- 1st symptom that pt has Type 1 DM
- Glucose >300
- Low bicarb
- Ketones / Ketouria
- Acidic pH <7.3
DKA
What is the pre-dominating factor in estimating osmolality?
Na
If hyperosmolality is not due to high Na, what other 4 things causes it?
Ineffective osmoles (permeable)
- Advanced renal failure (urea)
-
Alcohols
- Mannitol, ethanol, glycerol, isopropanol
- Hypertonic Hyponatremia
- Hyperglycemia
(HA HA)
Hyperglycemic Hyperosmolar State
- Occurs more commonly in DM1 or DM2?
- Hyperglycemia > ___ mg/dL
- Serum osmolality > ____
- Blood pH of what?
- type 2
- Hyperglycemia: >600
- Osmolality: >310
- pH: >7.3 (no acidosis)
What is this?
- Hyperglycemia without ketones
- minimal ketonuria/ketonemia
- NORMAL anion gap (<14)
- Serum bicarb >15
Hyperglycemic Hyperosmolar State
Clinical findings of what?
- Profound dehydration (dx/tx delayed until fluid deficit reaches 6-10 L)
- Non-ketotic
- Polydipsia / Polyuria
- Neuro changes (ranging from nystagmus - coma)
HHS
(hyperglycemic hyperosmolar syndrome)
Lab results of what condition?
- Plasma glucose: 800 - 2400 mg/dL
- Serum urea nitrogen elevations >100 mg/dL typical
HHS
( hyperglycemic hyperosmolar syndrome)
HHS treatment
- FLuids to restore UOP to ___ mL/h or greater
- Hypovolemic sxs (hypotension/oliguria) are treated w/ what?
- 0.45% saline may be utilized for maintenance as body fluids are markedly HYPERosmolar
- 50
- 0.9% normal saline
HHS treatment
- Once blood glucose reaches ____ mg/dL, fluid replacement should include 5% dextrose in either water, 0.45% NS, or 0.9% NS
- Maintain glycemia levels of 250-300 mg/dL in order to reduce the risk of what??
- 250
- cerebral edema
HHS treatment
- Treatment w/ what can be delayed??
- FLuid replacement ALONE can decrease hyperglycemia by correcting the hypovolemia, which can then increase both glomerular filtration & renal excretion of glucose.
Insulin can be delayed
HHS tx
- If there is ____, start insulin rate at 0.05 units/kg/h (bolus not needed) & titrate to lower blood glucose levels by 50-70 mg/dL /hour
Ketonemia
HHS tx
- If the pt had ketonemia and you started insulin and they are now stabilized (blood glucose fell to around 250), then insulin can be given via what route?
Subcutaneously
HHS tx
- Potassium should be monitored closely
- Potassium chloride replacement should proceed liberally, unless what 2 conditions are present???
- CKD
- Oliguria
HHS tx
- Severe hypophosphatemia (<1 mg/dL) during insulin therapy, what is the tx?
Phosphate replacement for ketoacidotic pts
What is this?
- SEVERE insulin deficiency
- Marked elevations of glucagon, cortisol, GH, epinephrine, norepinephrine
Diabetic Ketoacidosis (DKA)
Most cases of DKA occur in which type of DM?
Type 1 DM
- already diagnosed pts or may be 1st manifestation of type 1 DM
DKA is usually preventable by self monitoring what 2 things?
- Blood glucose
- Blood/Urine Ketone levels
DKA
- What is the most common precipitating factor??
- Other causes: insulin omission, pancreatitis, MI, stroke, and drug use
Infection
Causes of what?
Which one is MC cause?
- Insulin deficiency (failure to take enough)
- Iatrogenic (glucocorticoids)
- Infection
- Inflammation (pancreatitis, cholecystitis)
- Ischemia/infarction (myocardial, cerebral, gut)
- Intoxication (EtOH, drugs)
DKA
(INFECTION is MC cause)
Sxs of what?
- N/V
- Abd pain
- Polydipsia / Polyuria
- Enuresis
- “fruity” acetone breath
DKA
Sxs of what?
- Kussmaul breathing
- 2 signs of hypovolemia?? __ & ___
- AMS
- ____ is rare & indicated prolonged period of this condition
DKA
- Hypovolemia: hypotension & tachycardia
- Coma is rare
Acronym for DKA
- KUSSMAL
- K: ketones
- U: uremia
- S: sepsis
- S: salicylates
- M: methanol
- A: aldehydes
- L: lactic acidosis
Initial eval of DKA (4)
- ABCs
- Mentation
- Precipitating factors
- Volume status
What will a BMP show in pt w/ DKA?
- Glucose, Anion gap***, bicarb
- potassium (up or down)
- Na (low) - hyponatremia
(We want to close the gap!!)
What test should be ordered if HCO3 is low in pt w/ DKA?
ABG
What lab value may be elevated in pt w/o pancreatitis who is in DKA?
Amylase
DKA or HHS?
- GLucose >250
- pH <7.3
- HCO3 <18
- MODERATE ketonuria or ketonemia
DKA
DKA or HHS?
- Glucose >600
- pH >7.3
- HCO3 >15
- MINIMAL ketonuria & ketonemia
HHS
______ (increased anion gap) is principally caused by increased production of ketoacids w/ minor contributions from lactic acid / free fatty acids
Metabolic Acidosis
Describe the levels of K, phosphate, and Mg
Initially, serum K & phosphate are normal or high, but invariably there is total body depletion of K, phosphate, and Mg.
If plasma glucose levels are <250 = “euglycemic ketoacidosis) caused by what 3 things?
- Fasting/Starvation
- ETOH
- Pregnancy
It is important to prevent the development of hypoglycemia to reduce the likelihood of _____, which could result from too rapid decline of blood glucose…
Cerebral Edema**
DKA tx
- Usually require large volume resuscitation!!
- IV insulin drip continued till GAP is closed!
- Pts may require what type of IVF prior to gap closing?
- What 4 levels can be deceiving while BS remains high??
- Dextrose containing IVF
- K, phosphorus, Sodium, Mg
- DKA patients should be admitted to what hospital department?
- What 2 “special” things might they need for management?
- ICU
- PICC & ABG
DKA summary:
- DKA usually evolves gradually or rapidly?
- What are the early sxs? (4)
- As DKA worsens, what symptom worsens?
- ABCs
- Large IVs (FLUIDS, FLUIDS, FLUIDS)!!
- Rapidly
- N/V/ abd pain, hyperventilation
- mental status worsens as DKA worsens
DKA tx
- Monitoring of what levels is most important?
Electrolytes (K+)
