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Endo/Eye/Derm - Women/Men > EXAM 4 Inpatient Diabetes Management Flores > Flashcards

EXAM 4 Inpatient Diabetes Management Flores Flashcards

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1
Q

What are the factors or drugs that cause Hyperglycemia regardless of diabetes?

A

-glucocorticosteroids
-octreotide (treats diarrhea in colon cancer patients)
-parenteral/enteral nutrition

->check their A1c to see if they are diabetic

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2
Q

In an inpatient setting, when do we perform an A1c test?

A

On patients with diabetes or hyperglycemia (>140 mg/dl) if an A1c was not performed in the prior 3 months

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3
Q

What is the threshold to start antidiabetic therapy?

A

> 180 mg/dl

->start insulin and/or other meds

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4
Q

What is the goal blood glucose for critical patients (ICU) once they start on diabetic therapy?

A

140-180 mg/dl

studies have shown that for ICU patients 140-180 is safer to avoid complications of hyperglycemia and hypoglycemia

a goal of 110-140 may be appropriate in patients without significant risk for hypoglycemia

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5
Q

What are the complications of hyperglycemia

A

delayed wound healing
-CV disease (blood vessels)
-Neuropathy
-Nephropathy (damages the glomeruli)
-Retinopathy (eyes)

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6
Q

When would we allow blood glucose above 180 mg/dl?

A

-terminal ill patients
-severe comorbidities
-when we want to avoid hypoglycemia

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7
Q

What is the recommended goal range for patients who are non-critical ill in an inpatient setting?

A

for example patients in a floor bed
100-180 mg/dl

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8
Q

What is the perioperative blood glucose goal and how many hours before the surgery does it refer to?

A

100-180 mg/dl within 4 hours of surgery

hold oral agents and reduce basal insulin

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9
Q

When should an SGLT2i be held before the surgery?

A

3 days before surgery
4 days before surgery if it is ertugliflozin

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10
Q

When should Metformin be held before the surgery?

A

No metformin on the day of surgery

also hold other oral hypoglycemic agents in the morning of the surgery

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11
Q

How should NPH insulin be handled before the surgery?

A

-give half of the NPH dose
OR
-70-85% of long-acting analog (Lantus, Tresiba) or pump basal insulin

-monitor BG every 2-4h and correct with insulin

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12
Q

When should a patient’s blood glucose be monitored before surgery?

A

monitor BG every 2-4h and correct with insulin
or pre-meal if they are eating

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13
Q

Why would sometimes a procedure be delayed before their A1c is in control?

A

To improve wound healing which may be required for a procedure

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14
Q

Can insulin dosing decisions and hypoglycemia assessment be based on the CGM of patients that they use at home?

A

can still use their CGM they use at home, but needs confirmation from point-of-care measurement, because the CGM may not be as accurate due to the stress on the body in the hospital

same for automated insulin delivery system with CGM -> need to confirm with point-of-care measurement (glucometer)

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15
Q

What is the recommended treatment approach for non-critical-ill patients in the hospital?

A

poor oral intake:
-Basal insulin or a basal plus bolus correction

adequate nutritional intake
- basal, prandial, and correction components (basal-bolus)

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16
Q

What would not be the best practice in diabetic patients in the hospital?

A

Sole use of a correction or supplemental insulin (sliding scale) without basal insulin

->so just a sliding scale is not recommended

may still see patients solely on a sliding scale if blood glucose is ok

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17
Q

What is the appropriate way to infuse insulin in critically ill patients?

A

IV continuous insulin infusion with Self-monitoring blood glucose (SMBG) every 0.5-2 hours
->as the patient gets better switch to injectables

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18
Q

How should insulin doses be adjusted if patients get to the hospital?

A

reduce by insulin home dose by 20-25% (usually the basal insulin)

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19
Q

How should insulin doses be adjusted if patients get to the hospital, in insulin-naive patients?

A

if they are eating:
0.5U/kd/d split for basal + bolus

if they are not eating:
0.25U/kg/d for basal

Not going to ask for doses

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20
Q

What is the approach to sending patients home?

A

start home meds 1-2 days before discharge

-if they were not using insulin before and were controlled, they may stop using the insulin they were started on in the hospital

-if they were on insulin they may need insulin adjustments (especially if their blood glucose is below 70 mg/dl)

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21
Q

How should non-insulin be handled in the hospital?

A

Metformin: stop on the day of surgery, also may hold before imaging procedures (contrast can impair renal function, metformin-induced risk of lactic acidosis)

-Sulfonylureas: hold due to risk of hypoglycemia (especially if they are not eating in the hospital)
-TZDs: held due to cardiac concerns
-GLP-1 agonist: they are doing studies right now -> stomach upset, pancreatitis risk

-DPP-4i: studies show benefit +/- insulin, hold Saxagliptin and Alogliptin in patients with HF

-SGLTS2i: don’t use if acutely ill - euglycemic DKA risk, might start with patients with HF

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22
Q

Which DPP-4i should be held in patients with HF?

A

Saxagliptin and Alogliptin

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23
Q

SGLT2i recommendation in the hospital

A

should be started or continued in patients with HF in the hospital

-if there are no contraindications and after recovery from acute illness
so if they are acutely ill - don’t start???

24
Q

When are hypoglycemic events likely?

A

-after giving insulin -> may reduce the dose
-at night -> adjust the dose or drug
-other drugs: if steroids were reduced then reduce insulin, octreotide
-the amount of nutrition
-patients unable to report hypoglycemia symptoms

25
Q

What are the disease states of a hyperglycemic crisis?

A

-Diabetic Ketoacidosis (DKA)
-Hyperglycemic Hyperosmolar State (HHS)

to prevent:
-Adherence
-Recognize highs
-Manage highs
-monitor Ketones
-cautious on Sick days

26
Q

Patients on sick days

A

-are they eating well
-are they still taking their meds
-they need to check their BG - enough strips

27
Q

Who is prone to be hyperglycemic with Ketones?

A

-patients with absolute insulin deficiency -> T1DM
-patients with T2DM that start needing insulin regimen
-patients with hx of DKA with ketones

28
Q

Difference between DKA and Ketosis

A

Hyperglycemia + Ketones (in the urine) = Ketosis
->its not a crisis yet

29
Q

How to treat Ketosis

A

-Hydration (oral at home), 1L NS in the clinic
-check labs to assess other factors of DKA

-give additional short-acting insulin at home or in the clinic:
mild ketones: Correction dose + 5% of TDD
moderate to severe: Correction dose + 10% of TDD

30
Q

DKA - HHS spectrum
Which symptoms do both have in common?

A

-increased Counterregulaotry hormones
-Hyperglycemia
-Dehydration

31
Q

What are the signs/symptoms of DKA?

A

usually with Absolute insulin deficiency (T1DM)

-Lipolysis goes up -> inc FFA to liver -> Hyperlipidemia

-Ketogenesis goes up -> Ketoacidioss (metabolic acidosis)

DKA ->
Diabetic: Hyperglycemia
K: Ketones
A: Acidosis (pH < 7.3) with anion gap (>15)

32
Q

Other specific symptoms of DKA

A

-Kussmaul respiration
-Fruity acetone breath

-N/V, abdominal pain
-minor mental status change

33
Q

What are the signs/symptoms of HHS?

A

Relative insulin deficiency -> since they have some insulin they can deal with HHS longer -> longer hydrated, BG level goes up longer

-Hyperosmolarity (>320 mOsm/kg)
-Hyperglycemia (>600 mg/dl)
-State of mental changes (stupor/coma)

34
Q

Which labs are different DKA vs HHS

A

-Arterial / Venous pH is slightly higher in HHS -> in DKA causes the pH to be lower in DKA

-Serum bicarbonate is higher in HHS (less compensation of metabolic acidosis since less ketones in HHS)

-urine and serum ketones are smaller in HHS
-Hyperosmolarity in HHS (> 320 mOsm/kg)
-Anion gap is variable in HHS, in DKA it is >10 or >12

35
Q

What are the first interventions in a patient having symptoms of hyperglycemia?

A

-Hydration, fluids (IV if in the clinic)
-give insulin (but not until we know K+ levels - wait until safe (shift of K into cells))
-check labs for ketones and acid-base status

36
Q

What might contribute to hyperglycemia leading to a hyperglycemic crisis?

A

-New Diagnosis
-Infection
-Inadequate insulin therapy (adherence, dosing, pump site failure)

-Alcohol use
-CV disease, cerebrovascular event, pulmonary event)
-unknown pregnancy (insulin resistance goes up)
-pancreatitis

37
Q

Meds that may contribute to hyperglycemic crisis

A

Corticosteroids
-Thiazide diuretics
-Sympathomimetic agents
-antihypnotics
-SGLT2-inhibitor

38
Q

What is the interaction between insulin and potassium (K)?

A

insulin shifts potassium into the cells
->Hypokalemia

so make sure it is safe to give insulin to patients in hyperglycemic crisis -> since their potassium might be low already from dehydration

39
Q

What should a patient’s K+ levels be to start insulin therapy?

A

greater than 3.3 mEq/L

40
Q

What are the doses for fluid therapy?

A

1 - 1.5 L during the first hour
OR 15-20 ml/kg/h for kids
-> continue until thermodynamically stable

41
Q

How should fluid therapy be continued after 1 hour?

A

-continue fluid at 250-500 ml/h (or 4-14 ml/kg/h)

choose NS if the corrected sodium is low

choose 1/2 NS if the corrected sodium is normal or elevated

42
Q

At what K+ levels should K+ replacement be considered?

A

< 5.3 mg/dl

often both insulin and potassium are started at the same time in different bags

43
Q

The patient’s K+ is at 4, what should be done?

A

the potassium level of 4 is in the range, however since we are giving insulin, the potassium will be shifted into the cell, so it is about to drop

->give K+ supplement: usually 20-30 mEq/L of KCl together with 1/2 NS at 250-500 ml/hr

44
Q

When would you consider a slower fluid rate?

A

-CKD (cant handle large fluid volumes, leading to fluid retention and electrolyte imbalances)

-heart failure patients

45
Q

What happens if fluid is pushed too quickly?
FYI

A

cerebral edema

46
Q

What should be added to the fluid as the hyperglycemia resolves?

A

Dextrose -> so that we can keep giving insulin -> until ketone resolves and the anion gap closes

-give D51/2NS (D5NS or D5W works too)

47
Q

When does a patient have high osmolality indicating HHS?

REMINDER

A

> 320 mOsmol/kg

if a patient with ketones, and an anion gap has normal osmolality -> they are on the DKA side of the spectrum

48
Q

How is Insulin therapy in a patient in the hospital initiated?

A

there are multiple ways
-start with a bolus: 0.1U/kg IV drip
-followed by continuous infusion: 0.1U/kg/h

-titrate the insulin drip to decrease glucose
by 50-70 mg/dl/h

49
Q

What should be done as the glucose reaches resolution (< 250 mg/dl)?

A

decrease insulin rate to 0.05 U/kg/h (or by 50%)
-add dextrose which allows us to keep giving insulin (we need to keep giving insulin otherwise the glucose may start to rise again, need dextrose to prevent hypoglycemia???)

50
Q

As the glucose resolves to below 250 mg/dl, what is the goal glucose level we want the patient to be?

A

100-200 mg/dl
->adjust insulin rate to be in the range

51
Q

What has to be done before the insulin drip is discontinued?

A

give basal insulin SQ 2-4h before stopping the IV drip

->basal insulin needs time to be absorbed into the bloodstream, without the basal insulin the patient would go back to DKA when the drip is stopped

52
Q

When should Phosphorus be replaced?

A

< 1 mg/dl

consider using K-Phos when both Phosphorus and K+ is low

53
Q

When should Bicarbonate replacement be considered?

A

Not routinely indicated

-consider if pH is <6.9
-at this point, the patient is very sick (severe acidosis)
-Bicarbonate can cause hypokalemia

54
Q
A
55
Q

How should patients be transitioned to SQ basal insulin after resolving?

A

use 60-80% of the most recent daily insulin infusion dose as SQ basal insulin

other option:
-0.5-0.8U/kg/day

-start 2-4h before stopping the insulin infusion

56
Q

What is the discharge plan for patients who have an A1c of >9%?

A

-Discharge on basal/bolus regimen at same hospital dose OR

-Discharge on oral agents (their home meds) and 80% of hospital basal dose

-for 7-9%:
-restart the outpatient regimen with the addition of basal insulin at 50% of the hospital dose

-follow up: 1-2 weeks or 1 month with PCP

Endo/Eye/Derm - Women/Men (30 decks)

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