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Diabetes 1


T1DM is identified by: serologic autoimmune markers of pancreatic islet dysfunction (beta cell destruction) and genetic markers (HLA)
DM & wt loss Insulin def in DM kids impairs glucose utilization in sk mx & increases fat / mx breakdown. Initially, appetite is increased; over time, kids may become anorexic, contributing to wt loss
Acute life threatening complications of DM include: DKA; Nonketotic hyperosmolar syndrome (high blood viscosity; these patients usually have extremely high blood glucose)
Incidence of acute life threatening complications of DM DKA ( 4.6-8 episodes per 1000 pts w/ DM); hyperglycemic hyperosmolar syndrome (HHS: < 1% of all primary DM admissions)
DKA: economics DKA tx = 1 in 4 healthcare dollars for direct spend on T1DM pts; 100k hosps / yr for DKA; $13,000 / DKA pt; >1B dollars / yr
DKA: Dx Hyperglycemia; Ketonemia; Acidemia. Elevated glucose (>250), AGMA, PO4, K, pos ketones, mild low Na
DKA: Presentation N/V; weakness/lethargy; fruity breath; abdominal pain; hyperventilation (Kussmaul); dehydration & ortho hotn
Why Ketones in DKA? Insulin deficiency: increased lipase activity increases breakdown of TGs to glycerol & free fatty acids (= precursors to ketone bodies)
DKA mgmt 1st: Fluid replacement. Continuous regular insulin drip. Potassium & EKG/tele. Tx underlying cause.
When to Start Insulin Tx for T1DM multi dose insulin injxns (3–4 / day of basal & prandial insulin) or CSII tx ; matching prandial insulin to CHO intake, pre-meal blood glu, & anticipated activity; for many pts (esp if hypoglycemia is problem), use of insulin analogs
Rapid acting insulin: Lispro; Aspart; Glulisine
Short acting insulin: Regular
Intermediate acting insulin: NPH
Basal insulin: Glargine (Lantus); Detemir (Levemir)
Premixed insulin: 70/30 regular; 70/30 aspart; 75/25 lispro; 50/50
Action: Lispro, Aspart Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 4-6 h
Glulisine Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 6-8 h
Action: Regular Onset of Action 30-60 min; Peak 2-4 h; Duration of Action 6-10 h
Action: NPH Onset of Action 1-2 h; Peak 4-8 h; Duration of Action 10-20 h
Action: Glargine Onset of Action 1-2 h; Peak: None; Duration of Action 24 h
Action: Detemir Onset of Action 1-2 h; Peak 6-8 h; Duration of Action 12-24 h
Fx on insulin absorption: Exercise Strenuous use of injected limb within one hour
Fx on insulin absorption: Massage of area Do not rub site vigorously
Fx on insulin absorption: Temperature Heat increases, cold decreases
Fx on insulin absorption: Site of Injection Abdomen>arms>thigh (R & N only)
Fx on insulin absorption: Lipohypertrophy Delays absorption
Fx on insulin absorption: Large doses (>80 units) Delay onset and duration
Factors affecting insulin absorption in hospitalized pt Severity of illness; Meds (g’corticoids, pressors); Diet: different, unpredictable; Type of diabetes; Previous glycemic ctrl; Setting: ICU vs ward
Fx on insulin absorption: Jet injectors Increase absorption rate
Fx on insulin absorption: Certain insulin mixtures Lente causes loss of rapid acting insulin action
Fx on insulin absorption: Large doses (>80 units) Delay onset and duration
Fx on insulin absorption: Suspension form Proper resuspension needed
Use of sliding scale insulin: should NOT be used as monotherapy
Potential for hypoglycemia is increased in: Acute illness; Erratic food intake; Poor coordination of insulin dosing with meals
Hypoglycemia Tx: D50 IV Dextrose (D50) Admin = most rapid method of alleviating hypoglycemia; appropriate for pts who are unconscious, severely symptomatic, or NPO
Hypoglycemia Tx: pts who are alert and able to eat should: be given 15 gm CHO in a rapidly available form (ie, ½ cup of fruit juice, 4 oz nondiet soda, or 3 glucose tablets)
Hypoglycemia Tx: A common error: to over-treat hypoglycemia with an excess of carbohydrate (this, plus counter-reg hormone response to hypoglycemia, facilitates subsequent hyperglycemia)
Troubleshooting low blood sugars N/V (consider checking BG before meal & rapid insulin just after, if N/V consistent prob); sepsis? Renal/Liver prob? Too much insulin? Other endocrine prob (hypothyroid/ adrenal)
Troubleshooting high blood sugars First find underlying cause (insufficient insulin dosing OR other)
high blood sugars: causes other than insuff insulin dose Infxn; Dehydration; Cardiac; hormones (ie epinephrine); Stress / Surgery; Rebound from a prior episode of HYPOglycemia ; Medications (ie, steroids)
Metabolic syndrome (insulin resistance syn): Dx: 3 of 5: Waist circum >40 (M) / >35 (F); TG ≥150; HDL <40 (M) / <50 (F); BP ≥ 130/85; FPG ≥110
Metabolic syndrome: other major dx criteria acanthosis nigricans, estd T2DM, central obesity
Metabolic syndrome: minor dx criteria hypercoagulability , PCOS, vascular endothelial dysfunction, CAD, microalbuminuria
Whipple triad (hypoglycemia) hypoglycemic sx (tremor, confusion, sweating, nausea, hunger), low BS, sx resolve when glucose is normal
Hypoglycemia glucose <60; usu 2/2 med use; poss insulinoma
Pronounced hyperglycemia with insulin deficiency = DKA
DM: Ocular Complications Retinopathy; Cataracts; Glaucoma; pts w/ DM need an annual ophthalmologic exam
Diabetic Retinopathy: microaneurysms = Small blow-out swellings of blood vessels
DM Retinopathy: Exudates = Small leaks of fluid from damaged blood vessels
DM Retinopathy: hemorrhages Small bleeds from damaged blood vessels
DM Retinopathy: Blood vessels: may become blocked => reduced blood & oxygen to small sections of retina; New abnormal vessels may grow from damaged vessels (AKA proliferative retinopathy); new vessels are delicate & bleed easily
Treatment of renal failure due to DM: renal transplant more promising than dialysis (if patient eligible)
Most common complication of DM: Neuropathy
Characterize DM Neuropathy Distal symmetrical polyneuropathy with loss of motor & sensory function, esp. of long nerves. Mononeuropathy (eg, peripheral or CN)
DM Peripheral Neuropathy clinical features Peripheral: painful diabetic neuropathy with hypersensitivity to light touch.
DKA: Dx Hyperglycemia; Ketonemia; Acidemia
Ketones: Why Insulin def: Inc lipase activity increases breakdown of TGs to glycerol & free fatty acids (= precursors to ketone bodies)
DKA mgmt continuous insulin drip (monitor) (MOST IMPORTANT); Fluids; Potassium; EKG;
Somogyi Hypoglycemia triggers counter-regulatory hormones -> hyperglycemia. Manage insulin to prevent hypoglycemia
Dawn phenomenon Due to waning insulin levels -> early AM hyperglycemia (not preceded by hypo), mediated by nocturnal GH secretion. Give LA insulin later in PM
Hyperglycemic hyperosmolar nonketotic state = Almost always in DM2. High blood viscosity. Glucose >600, osmo >350, dehydration/oliguria 2/2 intense osmotic diuresis. Low K. Lactic acidosis: poor prognosis
HbA1c & DM dx Dx s/b made if A1c <6.5; s/b confirmed w/ repeat test; not nec for sx pt w/plasma glu ≥200 mg/dL
DM clinical features Polyuria; Polydipsia; Wt loss; Fatigue; blurred vision; Suscept to infxn; May be asymptomatic, esp Type 2
DM: Polyuria occurs when: serum glu >180 mg/dL (exceeds renal threshold for glu, which leads to increased urinary glu excretion)
DM: Glycosuria causes: osmotic diuresis (ie, polyuria) and hypovolemia
Rapid acting insulin: inject when: within 15 min of meal; as rescue: w/o regard to meals
Glulisine (Apidra)(rapid): Dosing: 15 min prior to meal OR within 20 min after starting a meal
Short acting insulin: inject when: within 30 min of meal; as rescue: w/o regard to meals
NPH: typically inject how often: x2 / day (depending on meal schedule)
Detemir is bound to ? and is good out of the fridge for: bound to albumin; good for 42 days out of refrigerator
If change in basal insulin: BID NPH to long-acting: Reduce TDD by 20%; administer total dose QD
50/50 rule with NPH as basal: Decrease amt used as bolus by 20%
Standard insulin split mix 2/3 of TDD in AM (1/3 short acting; 2/3 intermed); 1/3 of TDD in PM (1/2 short acting, 1/2 intermed)
Rule of 1800 formula 1800 / TDD = x (mg/dL changed by 1 unit insulin) = correction factor
Rule of 500: formula 500 / TDD = x gm CHO covered by 1 unit insulin
Which insulins are cloudy? NPH; mixes
Which insulin may be given IV? Regular
T1DM diet recs 45-65% CHO, 10-35% pro, 25-35% fat; <33 mg/day chol
DM eval Microalbuminuria. Alb/Cr ratio. Lytes. Lipids. TSH (TD1 only). Check for PVD. Eye exam (DM2 annual, 5 yrs post-DM1 dx). Foot exam.
DM Autonomic Neuropathy clinical features Gastroparesis; hotn; bladder dysfn/UTI; erectile dysfunction
Other complications of DM DM amyotrophy (painful wasting of quad mm in older men). Necrobiosis diabetica (skin), Candida infxn. Osteopenia.
HHN state mgmt Replace fluids & lytes. Insulin required. Abx if underlying infxn
Created by: Adam Barnard Adam Barnard