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PHM 602- Diabetes > Inpatient DM Management > Flashcards

Inpatient DM Management Flashcards

1
Q

Premeal blood glucose goal

A

<140

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2
Q

Random blood glucose goal

A

<180

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3
Q

When do you modify therapy (what BG level)

A

<100

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4
Q

Hyperglycemia is defined as…

A

BG >140

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5
Q

Hypoglycemia is defined as…

A

BG <70

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6
Q

Severe hypoglycemia is defined as…

A

BG <40

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7
Q

Factors that can affect hyperglycemia

A

Prolonged use of correctional insulin as monotherapy
TPN and enteral feeds
Medication use (corticosteroids, thiazides)
Failure to adjust regimen based on BG patterns
Poor coordination between testing and timing of insulin delivery

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8
Q

Patient-specific factors that affect hypoglycemia

A

Advanced age, decreased PO intake, chronic renal failure, liver disease, history of frequent or severe hypoglycemia

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9
Q

Inpatient factors that affect hypoglycemia

A

Change in diet
Medication use (beta-blockers, fluoroquinolone ABX, alcohol)
Failure to adjust regimens based on BG patterns
Poor coordination between testing and timing of insulin delivery

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10
Q

3 components of insulin regimen for hyperglycemia

A 
Basal insulin (long-acting)- manages fasting state
Nutritional insulin (short or rapid-acting)- prevents rise in glucose, but don't give if patient is NPO or skip a meal
Correctional insulin (short or rapid-acting)- extra insulin to correct BG that's still above target, given by a scale
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11
Q

Insulin therapy for T1DM

A

0.2-0.4 units/kg/day
Give 50-60% as basal insulin and 40-50% as nutritional insulin
Correctional insulin may be given for BG above goal
Adjust dose according to BG values, change in clinical status, or if patient is made NPO

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12
Q

Insulin therapy for T2DM

A

D/C all PO and non-insulin injectable antidiabetic agents
Insulin naive: 0.3-0.5 units/kg
Outpatient insulin use: decrease outpatient dose by 20-25%
50% of TDD is given as basal insulin, other 50% is split into 3 and given as mealtime insulin
Correctional insulin may be given for BG above goal

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13
Q

First thing to do when a patient is admitted

A

Assess patient for DM history- are they T1DM or T2DM?

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14
Q

If the patient has no history of DM and their BG is >140, what do you do?

A

Obtain lab BG testing and monitor based on clinical status

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15
Q

When is it recommended to obtain an A1C?

A

All patients with DM history or if they have hyperglycemia, if there is no A1C from the last 3 months, no history of diabetes but they are hyperglycemic -> start POC BG for 24-48 hours while checking A1C

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16
Q

What A1C level indicates diabetes?

A

≥6.5%

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17
Q

In patients with DM history or A1C ≥6.5%, what do you monitor regularly?

A

Blood glucose

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18
Q

Risks with insulin

A

Using “U” instead of “units”
Insulin as floor stock
Multiple concentrations of IV compounded insulin infusions/non-standard insulin infusion rates
Testing and reporting errors with BG testing

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19
Q

Risk reduction strategies

A

Collab with dieticians to adjust parenteral nutrition
BG testing with insulin administration and meal delivery
Good communication during patient transfer
Double check orders for completion and accuracy when prescribing and verifying
Avoid medication errors
Stock only one concentration of insulin infusion bags
Standardize insulin protocols

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20
Q

What can pharmacists do for insulin risk reduction?

A 
Discourage sliding scale insulin
Counsel patients before discharge
Develop treatment protocols
Minimize medication errors
Formulary-decision making
21
Q

What are the most severe metabolic disorders of DM?

A

DKA and HHS

22
Q

Precipitating factors of DKA and HHS

A

Infections, MI, medications, noncompliance, poor sick day management, pancreatitis, drug/alcohol abuse, inadequate dose or D/C of insulin, new onset T1DM

23
Q

DKA clinical picture (signs and symptoms)

A

polyuria, polydipsia, weight loss, weakness, mental status change, Kussmaul respirations, N/V, abdominal pain

24
Q

Glucose level in DKA

A

> 250

25
Q

pH in DKA

A

<7.3

26
Q

Anion gap in DKA

A

> 12

27
Q

Ketones in DKA

A

positive

28
Q

Effective serum osmolality in DKA

A

<320 mOsm/kg

29
Q

HHS clinical picture (signs and symptoms)

A

Same as DKA but with seizures and hemiparesis

30
Q

Glucose level in HHS

A

> 600

31
Q

pH in HHS

A

normal

32
Q

Anion gap in HHS

A

variable

33
Q

Ketones in HHS

A

negative

34
Q

Effective serum osmolality in HHS

A

> 320 mOsm/kg

35
Q

Initial fluid management

A

15-20 ml/kg for the first hour

36
Q

Subsequent management for severe hypovolemia

A

Use NS

37
Q

Subsequent management for mild dehydration

A

Serum sodium normal or high- 1/2 NS

Serum sodium low: NS

38
Q

Subsequent management for cardiogenic shock

A

Pressors and monitor hemodynamics

39
Q

If the BG is 200mg/dl in DKA or BG 300mg/dl in HHS, what fluids do you give the patient?

A

1/2NS and D5W

40
Q

Insulin therapy dosing in DKA or HHS

A
  1. 1 units/kg as an IV bolus, then 0.1 units/kg/hour continuous infusion
  2. 14 units/kg/hr as maintenance dose
41
Q

When do you decrease the insulin infusion rate and what do you decrease it to?

A

Decrease to 0.02-0.05 U/kg/hr IV when:

DKA: BG 200mg/dl (until resolution, BG 150-200)
HHS: BG 300mg/dl (until patient is mentally alert, BG 200-300)

42
Q

When to switch from IV insulin to SQ insulin

A

When there is resolution of crisis and patient is able to eat, initiate SQ insulin and overlap with IV insulin for 1-2 hours

43
Q

What defines DKA resolution?

A

BG <200 and TWO of the following:

Venous pH >7.3
Anion gap ≤12 mEq/L
Serum bicarb ≥15 mEq/L

44
Q

What defines HHS resolution?

A

Normal osmolality AND normal mental status

45
Q

Potassium treatment when K+ <3.3 mEq/L

A

hold insulin and replete at 20-30 mEq/hr until K+ is >3.3 mEq/L

46
Q

Potassium treatment when K+ 3.3-5.3 mEq/L

A

20-30 mEq/L K+ should be given with every L of fluid

47
Q

Potassium treatment when K+ >5.3 mEq/L

A

don’t give potassium until it falls below the upper limit of normal, monitor q2h

48
Q

Sodium bicarb treatment

A

Only use if pH <6.9, 2 ampules of sodium bicarb in 400mL of water and 20mEq of K+ over 2 hours, repeat q2h until the pH >7

49
Q

Insulin naive dosing when transitioning from IV to SQ insulin

A

TDD of 0.5-0.8 units/kg with 50% being basal and other 50% divided into 3 for mealtime insulin

PHM 602- Diabetes (19 decks)

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