secondary care Flashcards
potential blood sample contaminants that could result in falsely high K+ values
- EDTA-K (anticoagulant used in blood bottles -> EDTA binds bivalent ions (Calcium and Magnesium) => Ca and Mg may be very low
- drip with K+
4 causes of falsely high K+ blood results
- delayed separation of cells
- haemolysis
- contamination
- thrombocytosis/leukocytosis
HbA1c diabetic targets (2)
- 48 mmol/L for most diabetics
- 53 mmol/L if on hypo causing meds
what diabetic medications should be stopped in the case of DKA or illness (and what shouldn’t be)
stop SGLT2is and sulphonyureas due to risk of dehydration; do not stop metformin
in what case should metformin be stopped
if eGFR<30
when is a GLP1 agonist good to give
if BMI >30 (helps weight loss by increasing satiety)
who might ultra long acting insulin be given to (2)
- elderly pts who are visited by district nurses
- frequent DKA pts (poorly controlled)
sites of insulin injection from fastest to slowest absorption time
- abdomen
- backs of arms
- legs
- buttocks
if on 2 different insulins, what should be recommended about the injection sites
the injection sites should be two completely different areas to avoid interaction
apart from appearance, why is lipohypertrophy bad
insulin can’t be absorbed as well here
can lipohypertrophy be reversed
if small areas then yes, but no if severe
why trying to combat hyperglycaemia, what should be done to the insulin dose
increase it by 10%
why trying to combat hypoglycaemia, what should be done to the insulin dose
reduce insulin by 10-20% and review in 1 week (needs time to take effect)
correcting hypos take priority over hypers
what blood glucose value is considered hypoglycaemic
<4
7 early hypoglycaemiasigns
adrenergic symptoms
1. palpitations
2. tremor
3. anxiety
4. sweating
5. hunger
6. headache
7. parasethesia
6 late hypoglycaemia signs
neuroglycaemic signs
1. confusion
2. unusual behavior (e.g. overly aggressive)
3. drowsiness
4. speech difficulties
5. seizure
6. coma
how to treat a hypo
ifcan eat - give simple sugars e.g. orange juice, 5 glucose tabs, dextrose tables, jelly babies, 2 glucogel
repeat up to 3 times until BG reaches 4mmol -> if not then IV dextrose may be required
follow up with a starchy snack (once BG is >4)
if can’t eat then IV dextrose
ketone values
<0.6 - normal
0.6-1.59 - slightly high, increase monitoring
1.6-2.9 - risk of DKA, contact diabetes team/GP
>= 3.0 - high risk of DKA, get medical help immediately
how should an IV insulin infusion be stopped
stop it so that there is an overlap with the normal insulin dose - IV insulin only has a half life of 5 mins and so the normal dose must be given within this time
what are the 2 categories of diabetes complications
- microvascular
- macrovascular
what 3 things should be checked in the diabetes annual review to account for macrovascular complications
- BP
- BMI
- cholesterol levels
what is checked in a diabetes annual review (11)
- blood pressure
- blood glucose (HbA1c)
- cholesterol
- eye screening (every 2 years)
- foot and leg check
- kidney test
- dietry advice
- emotional and physical support
- flu jab
- smoking cessation (advice)
- pregnancy (advice)
how often do diabetic get their eyes checked if no visual problems
every 2 years
what 3 areas are affected by microvascular complications and how should their function be checked
- kidney - eGFR, albumin:Creatanin ratio (give ACEi/ARB if high)
- nerves - foot examination, ask about autonomic symptoms
- retinopathy - retinal exam
what are the 2 types of neuropathy that can arise w diabetes and what are symptoms
- peripheral - loss of sensation in feet and hands (glove and stocking distribution), ulcers, paresthesia etc.
- autonomic - urinary incontinence, postural hypotension, gastroparesis
3 stages of diabetic retinopathy and what can be seen in each
- background retinopathy - microaneuyrism, hard exudate
- preproliferative - cotton wool spots, haemorrhages
- proliferative - neovascularisation ->can lead to vitreous haemorrhage
what does taking a SGLT2i for diabetes increase the risk of
normal glycaemic DKA -> decreased insulin levels as a result of the drug leads promotes gluconeogenesis and lipolysis -> increased ketone body production
what can uclers to the bone pose a risk of
osetomyelitis
what does the number in insulin names indicate e.g. Humalog mix 25
the percentage of short acting insulin -> 25% short acting and 75% intermediate acting in the example
why does carb counting make it difficult to prescribe insulin for a pt
they take variable amounts of insulin depending on their carb intake so hard to prescribe a fixed rate => give a range of insulin doses
when prescribing variable rate insulin, what should happen to the pts normal insulin prescription
short acting should be stopped but NEVER stop regular long acting dose
indications for variable rate insulin (3)
- nil by mouth (e.g. pre-op)
- vomiting and can’t eat
- DKA (resolved buts still not eating)
what are examples of typical diabetic foot chracteristics (4)
- high arch
- foot deformity (e.g. charcot’s, amputatio)
- muscle wasting
- toe clawing
what is an early sign of charcot’s foot
the affected foot is warmer than the other
why is KCL usually given in the second bag of fluids in the DKA protocol
insulin causes hypokalaemia - it promotes the entry of potassium into skeletal muscle and liver cells by increasing the activity of the Na- K-ATPase pump
3 mainstays of DKA mgx
- insulin (0.1g/kg fixed rate)
- fluids - first bag normal saline 1L over 1hr
- KCl - 2nd/3rd bag NaCl 1L + KCl 40mmol over 2hrs
(4. glucose - if BG <14 then give dextrose 10%)
what fluid dose is given if haemodynamically unstable (BP <90/60)
- 500ml saline stat (over 15min), continue until BP normal
- if frail/at risk of fluid overload (e.g. HF) give 250ml stat
what electrolyte disturbance is seen in addisonian crisis and why
hyponatremia and hyper kalemia -> lack of mineralcorticoids => no RAAS stimulation so Na+ not retained in kidneys -> fluid not retained (so BP drops) and instead K+ is retained (Na+/K+ pump is not initiated in the DCT due to RAAS system not working)
why is low glucose seen in an addisonian crisis
due to low cortisol levels -> cortisol causes gluconeogenesis + gllucogenesis (i.e glucoe is high)
what happens to BP in addisonian crisis and why
BP drops -> no mineralcorticoids => no aldosterone to control BP levels
what other conditions are related to diabetes
other autoimmune conditions e.g. vitiligo, IBD, coeliac’s, pernicious anemia, hypothyroidism
what 2 careers can diabetics not do
pilot and military
what antibodies should be tested for if T1DM suspected
- anti - GAD65
- anti - IA2
- insulin antibodies (IAA)
- anti - zinc transporter 8
- C peptide (released when insulin made)
how is osmolarity calculated
2(Na+ + K+) + urea + glucose
when should pancreatic cancer be scanned for in diabetics
if >60 and new diabetes or if there is a big change in pre-existing diabetes
what should be recommended to T1DM pt who binge drink
have carbs after a night out-> stops sugars coming crashing down
if a diabetic pt has erectile dysfunction, what else are they likely to have
coronary heart disease (coronary bvs are smaller and so likely to be already blocked if larger penile arteries are blocked)
if a 9am cortisol test shows levels <100 what should be done
immediately start steriods -> but also maje sure to check their meds and whether they have just come off night shifts r other things that can cause abnormal 9am cortisol
is 9am cortisol test is 100-350 what should be done next
short synacthen test
if a pt is taking oestrogen exogenously shoud they have a cortisol test
no - must omit oestrogen for 6 weeks prior
when should cortisol levels reach their peak in the short synacthen test
after 30 mins
what mgx is needed for congenital adrenal hyperplasia
lifelong steroid replacement
a steroid card is required if you are taking steroids for longer than how many weeks
> 4 weeks
what can be eaten to help reduce LDL levels
plant sterols
how much does 10g of carb raise BG levels by
2.3 mmol
what is a complication of thyroidectomy and what will this show on ECG
damage to parathyroid glands -> hypocalcaemia, will have long QT on ECG
what is the cushing reflex
a physiological nervous system response to acute elevations of intracranial pressure (ICP), resulting in the Cushing triad of:
1. widened pulse pressure (increasing systolic, decreasing diastolic)
2. bradycardia;
3. irregular respirations
what is there a risk of due to basal insulin pump malfunction
DKA -> give some back up insulin pens as there is no insulin to fall back onw
what is glycaemic index and what affects this
the rate at which carbs are broken down into glucose -> fat and protein can affect this rate e.g. custard has a low GI as it contains fat and protein which slows down carb breakdown
what is glycaemic load
number that estimates how much the food will raise a person’s blood glucose level after it is eaten
glycaemic load calculation
glycaemic load = (Glycaemic Index x carbohydrate intake)/100
what is the 15:15 rule for hypglycaemia treatment
15g high GI carb, wait 15 mins
why is only IV hydrocortisone given as steroid replacement in addisonian cris
at high doses hydrocortisone acts as both a mineral and glucocorticoid => no role for fludrocortisone
what severe complication can occur in pts taking carbimazole and what is the mgx
agranulocytosis - give GCSF
2 causes for hypercalcaemia
- hyperparathyroidism
- malignancy (myeloma, PTH secreting, bone)
