Kirila DSA Chapter 27 CMDT Flashcards
EOD for type 1 Diabetes?
- 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
EOD for Type 2 Diabetes?
- > 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
What is the hygiene hypothesis?
-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
Which Genetic defect of pancreatic B cell function is the one that isn’t that rare?
MODY3 (HNF-1alpha)
-maturity onset diabetes of the young
What is Metformin used for?
-tx of type 2 diabetes
how does Metformin work?
- -increases hepatic AMP activated ptn kinase activity
- which reduces hepatic gluconeogenesis and lipogenesis
How is metformin metabolized?
- TRICK QUESTION
- it’s not
- gets excreted by kidneys unchanged
When do we start metformin?
at the diagnosis
Why can’t we give ppl metformin if they have renal issues?
- 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!
What is Regular insulin?
-short acting soluble crystalline zinc insulin whose effect appears within 30 minutes after SQ injection and lasts 5-7 hrs
When should we use an IV route to give regular insulin
- DKA
- perioperative management
When a patient is in the hospital, what route of insulin therapy would we use and why?
-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
When are a lot of insulin antagonists (catecholamines, GH, and corticosteroids) mobilized?
in surgery!
What do we do for people with diabetes controlled with diet alone?
Not a whole lot
-if it gets bad, use short-acting insulin as needed
Should patients taking oral agents take them on the day of surgery?
- no!
- they need to be eating normally, and that doesn’t usually happen before or shortly after a hospital procedure
What is an important thing to order postoperatively to ensure adequate kidney function prior to restarting metformin therapy?
-Serum Creatinine!
fun fact, difference between major and minor surgery?
greater or less than 2 hours
When would be the best time to operate on a diabetic patient?
early in the morning
How is glucose controlled in the ICU?
-insulin infusions
How is glucose controlled on the general surgical and medical wards?
-sub cue
What is the fluid deficit in DKA in most patients?
4-5 L
What is the solution of choice to treat DKA?
saline! 0.9% (normal)
-gotta re expand that volume… and do it quickly
What do we give them for DKA after the fluid replacement?
-regular insulin IV
When dealing with a hyperglycemic hyperosmolar state (HHS), what do we do for treatment when it comes to fluid replacement?
- normal (0.9%) saline if hypovolemic
- 0.45% saline otherwise
What should we include in our fluid replacement once the blood glc reaches 250mg/dL?
5% dextrose
What is an important end point of fluid therapy?
-to restore urinary output to 50 mL/h or more
What is the principle source of lactic acid in lactic acidosis?
RBC’s, skeletal m., skin, and brain
Generally, when will lactic acidosis happen?
in Hypoxemia
When does lactic acidosis happen in people with Diabetes mellitus?
-When they have renal problems and can’t clear the metformin that they are given
What is the main clinical feature of lactic acidosis?
-marked hyperventilation
Lab findings for Lactic acidosis?
- bicarb and pH are low (duh)= metabolic acidosis
- absent ketones
- high anion gap
- hyperphosphatemia can be a clue for no particular reason
What is the anion gap?
- Serum sodium minus the sum of chloride and bicarbonate anions
- should be no greater than 15
How is the diagnosis of lactic acidosis confirmed?
by demonstrating a plasma lactic acid concentration of 5 mmol/L or higher
-remember to rapidly chill it and separate it
