Dr Hanif's Notes Flashcards
Definition of AKI and CKD
AKI: must fulfill one of the following
- increase creatinine >26.5mol within 48 hours
- increase creatinine >1.5 times baseline within 7 days
- urine output <0.5ml/kg/h for 6 hours
CKD: abnormal kidney structure or function present for >3 months.
- Trace previous 3–6 months RP to differentiate both
Contraindication for NIV
- Cardiac/ respiratory arrest
- Inability to protect airway: poor cough, excessive/ inability to clear secretion, decreased conscious state/ coma
- Upper airway obstruction
- Untreated pneumothorax
- Marked hemodynamic instability (eg: shock, ventricular dysrhythmias, severe acute MI, GI bleeding)
- Maxillofacial surgery
- Base of skull fracture
- Patient refusal
- Intractable vomiting
Hba1c Target
<= 6.5% (Tight)
- newly diagnosed
- younger age
- low risk of hypoglycemia
6.6-7%
- majority
7.1-8% (Less tight)
- elderly patients
- high risk of hypoglycemia
- advance CVD
- coronary artery disease
- heart failure
- advance renal failure (eGFR <45)
- decompensated chronic liver disease
Diagnostic Criteria for DKA, HHS
DKA (Fulfill all 3)
- Blood glucose >11mmol
- Ketone >3 or urine ketone >2+
- pH <7.3, HCO3 <15 mmol
HHS
- Severe dehydration
- Blood glucose >30mmol
- Osmolarity >320mOsmol/kg [2Na(mmol/L) + glucose(mmol/L)]
- pH >7.3, HCO3 >15mmol
- Blood or urine ketones nil/minimal
How to calculate SC Insulin dose once DKA resolve
Insulin naive
- Measure total daily dose insulin (TDD): 0.5-0.7U/kg/day then divided TTD into 50% for basal and remaining 50% as prandial (bolus) insulin
Already on insulin
- Use previous regime and adjusted accordingly
- Combine hourly dose of insulin after DKA resolve which maintain glucose 8-12mmol, then divide
Bridging of insulin
- Make sure allowed orally
- Actrapid 30min before meal and off IVI 30min after meal
Blood glucose target for operative patient
Pre-admission: optimal Hba1C <7, acceptable Hba1C <8.5
Admission: 6-10
Operative day: <10
Intraoperative: 6-10
Post-operative: 6-10 (awake on insulin); 4-12 (awake not on insulin)
Mx of DKA
§ Set 3 IV line on admission
□ Maintenance fluid 125ml/hr (6 pints in 24 hours) + K+ replacement
□ Fluid resuscitation line
□ IV insulin infusion 0.1u/kg/hr until ketosis resolve
- Restoration of fluid depletion
□ IVD 1L NS over 1h, then 2/4/6-8h
□ IVD maintenance 4-5 pint NS over 24h
□ Hourly urine output, aim 0.5ml/kg/hr - Suppression of ketosis and reversal of metabolic acidosis
□ FRIII 0.1U/kg/hr, cont until bedside capillary ketone levels are less than 1 mmol/L and pH >7.32
□ If glucose does not fall by 3mmol/h in first 2-3h despite adequate hydration, increase insulin by 1U/hr
□ Dextrose 5/10% if BG drops <14mmol/L, maintain 8-12mmol/L - Monitoring
□ Blood sugar hourly until out of DKA
□ Strict I/O charting
□ VBG & K+ at 1/4/6hr
□ 6hourly BUSE & ketone - Adequate potassium replacement
□ Start if <5.5mmol/L, maintain 4-5mmol/L
□ Monitor 6 hourly - Identification and Mx of any possible precipitating factors
- Resolution
□ Defined when pH >7.3 & serum ketone <0.6mmol
□ Overlap to basal bolus insulin
Resolution of DKA is defined as
- pH >7.3
- Plasma ketone <0.6mmol/L
Mx of HHS
- Replace fluid and electrolyte losses
□ 0.9% NS + K+ as required
□ Strict I/O charting
□ Hourly urine output, aim >0.5ml/kg/hr - Normalize the osmolarity
□ Aim gradual decline in serum osmolality at rate of 3-8 mOsm/kg/hr (Normal 275-295 mOsm/kg)
□ Rate of fall of plasma Na should not exceed 10mmol/L in 24 hours - Normalize blood glucose
□ Fluid replacement first - fall in BG 4-6mmol/L/hr
□ Low dose IV insulin (0.05 units/kg/hr)
□ Increase by 1 unit/hr if BG not falling by min 3mmol/L/hr in the first 2-3 hours
□ Dextrose 5/10% if BG <14mmol/L - Prevention of potential complications (eg: electrolyte imbalance, cerebral edema/ central pontine myelinolysis)
□ Start if <5.5mmol/L, maintain 4-5mmol/L
□ Monitor 6 hourly - Prevention of arterial or venous thrombosis
□ Prophylactic LMWH for full duration of admission unless contraindicated - Identify and treat precipitating factors
□ Eg: stroke/ MI/ ACS/ infection/ missed medication
Systemic inflammatory response criteria (SIRS)
- Temp: <36 or >38C
- HR: >90 bpm
- RR: >20
- WCC: <4 or >12
- Must fulfill 2-4 criteria to define patient as sepsis
Hypertensive urgency vs emergency
HPT Urgency
- BP >180/110 but asymptomatic
Aim: 25% reduction in BP over 24h but not <160/100
HPT Emergency
- BP >180/110 and symptomatic
- Eg: acute heart failure, dissecting aneurysm, ACS, HPT encephalopathy, acute renal failure, SAH/ ICH
Aim: reduce BP by 10-25% within certain min to hrs but not lower than 160/90
Calculate potassium correction
K+ Deficits = 0.4 x (4mmol - Actual K) x BW(kg)
K+ Requirement = 1-2mmol/kg
K+ Correction = (K+ Deficit + Requirement) / 13.3 [*this is to convert mmol into gram]
Lytic cocktail
IV Calcium gluconate 10% 10ml
IV D50% 50cc
IV Actrapid 10U
Mx of hypoglycemia
> Patient conscious & able to self-treat
- 15g simple/ rapid acting carbohydrate
> Patient unconscious
- IV D50% 25-50cc or
- IV D20% 75-100cc or
- IM glucagon 1mg
After given treatment
- Monitor blood glucose every 15min
- Repeat BG until >3.9mmol
- Evaluate causes of hypoglycemia
