Kirila DSA Chapter 27 CMDT

Question 1

EOD for type 1 Diabetes?

Answer 1

• polyuria, polydipsia, and weight loss
• random glc of 200
• plasma glc of 126 or more after an overnight fast, more than one occasion
• Ketonemia, ketonuria, or both
• Islet autoantibodies are frequently present

Question 2

EOD for Type 2 Diabetes?

Answer 2

• > 40 y/o
• polyuria and polydipsia (no Ketone probs)
• Candidal vaginitis in women may be an initial manifestation
• plasma glc of 126 or more after an overnight fast
• HBA1C 6.5%
• Htn, dyslipidemia, and atherosclerosis are often associated

Question 3

What is the hygiene hypothesis?

Answer 3

-in developed countries, childhood infections have become less frequent and so perhaps the immune system becomes dysregulated with development of autoimmunity and conditions such as asthmas and diabetes

Question 4

Which Genetic defect of pancreatic B cell function is the one that isn’t that rare?

Answer 4

MODY3 (HNF-1alpha)

-maturity onset diabetes of the young

Question 5

What is Metformin used for?

Answer 5

-tx of type 2 diabetes

Question 6

how does Metformin work?

Answer 6

• -increases hepatic AMP activated ptn kinase activity

- which reduces hepatic gluconeogenesis and lipogenesis

Question 7

How is metformin metabolized?

Answer 7

• TRICK QUESTION
• it’s not
• gets excreted by kidneys unchanged

Question 8

When do we start metformin?

Answer 8

at the diagnosis

Question 9

Why can’t we give ppl metformin if they have renal issues?

Answer 9

• they can’t excrete it
• high blood and tissue levels of metformin
• lactic acid overproduction
• watch out for serum creatinine levels too (>1.5 in men or 1.4 in women)
• ppl who drink and take this will get lactic acidosis because their hepatocytes can’t clear the lactic acid!

Question 10

What is Regular insulin?

Answer 10

-short acting soluble crystalline zinc insulin whose effect appears within 30 minutes after SQ injection and lasts 5-7 hrs

Question 11

When should we use an IV route to give regular insulin

Answer 11

• DKA

- perioperative management

Question 12

When a patient is in the hospital, what route of insulin therapy would we use and why?

Answer 12

-SQ or IV because the dose can be adjusted to match changing inpatient needs and it is safe to use insulin in patients with heart, kidney, and liver disease

Question 13

When are a lot of insulin antagonists (catecholamines, GH, and corticosteroids) mobilized?

Answer 13

in surgery!

Question 14

What do we do for people with diabetes controlled with diet alone?

Answer 14

Not a whole lot

-if it gets bad, use short-acting insulin as needed

Question 15

Should patients taking oral agents take them on the day of surgery?

Answer 15

• no!

- they need to be eating normally, and that doesn’t usually happen before or shortly after a hospital procedure

Question 16

What is an important thing to order postoperatively to ensure adequate kidney function prior to restarting metformin therapy?

Answer 16

-Serum Creatinine!

Question 17

fun fact, difference between major and minor surgery?

Answer 17

greater or less than 2 hours

Question 18

When would be the best time to operate on a diabetic patient?

Answer 18

early in the morning

Question 19

How is glucose controlled in the ICU?

Answer 19

-insulin infusions

Question 20

How is glucose controlled on the general surgical and medical wards?

Answer 20

-sub cue

Question 21

What is the fluid deficit in DKA in most patients?

Answer 21

4-5 L

Question 22

What is the solution of choice to treat DKA?

Answer 22

saline! 0.9% (normal)

-gotta re expand that volume… and do it quickly

Question 23

What do we give them for DKA after the fluid replacement?

Answer 23

-regular insulin IV

Question 24

When dealing with a hyperglycemic hyperosmolar state (HHS), what do we do for treatment when it comes to fluid replacement?

Answer 24

• normal (0.9%) saline if hypovolemic

- 0.45% saline otherwise

Question 25

What should we include in our fluid replacement once the blood glc reaches 250mg/dL?

Answer 25

5% dextrose

Question 26

What is an important end point of fluid therapy?

Answer 26

-to restore urinary output to 50 mL/h or more

Question 27

What is the principle source of lactic acid in lactic acidosis?

Answer 27

RBC’s, skeletal m., skin, and brain

Question 28

Generally, when will lactic acidosis happen?

Answer 28

in Hypoxemia

Question 29

When does lactic acidosis happen in people with Diabetes mellitus?

Answer 29

-When they have renal problems and can’t clear the metformin that they are given

Question 30

What is the main clinical feature of lactic acidosis?

Answer 30

-marked hyperventilation

Question 31

Lab findings for Lactic acidosis?

Answer 31

• bicarb and pH are low (duh)= metabolic acidosis
• absent ketones
• high anion gap
• hyperphosphatemia can be a clue for no particular reason

Question 32

What is the anion gap?

Answer 32

• Serum sodium minus the sum of chloride and bicarbonate anions
• should be no greater than 15

Question 33

How is the diagnosis of lactic acidosis confirmed?

Answer 33

by demonstrating a plasma lactic acid concentration of 5 mmol/L or higher
-remember to rapidly chill it and separate it