Endocrine
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| T1DM is identified by: | serologic autoimmune markers of pancreatic islet dysfunction (beta cell destruction) and genetic markers (HLA)
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| 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
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| Acute life threatening complications of DM include: | DKA; Nonketotic hyperosmolar syndrome (high blood viscosity; these patients usually have extremely high blood glucose)
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| 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)
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| 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
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| DKA: Dx | Hyperglycemia; Ketonemia; Acidemia. Elevated glucose (>250), AGMA, PO4, K, pos ketones, mild low Na
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| DKA: Presentation | N/V; weakness/lethargy; fruity breath; abdominal pain; hyperventilation (Kussmaul); dehydration & ortho hotn
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| Why Ketones in DKA? | Insulin deficiency: increased lipase activity increases breakdown of TGs to glycerol & free fatty acids (= precursors to ketone bodies)
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| DKA mgmt | 1st: Fluid replacement. Continuous regular insulin drip. Potassium & EKG/tele. Tx underlying cause.
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| 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
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| Rapid acting insulin: | Lispro; Aspart; Glulisine
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| Short acting insulin: | Regular
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| Intermediate acting insulin: | NPH
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| Basal insulin: | Glargine (Lantus); Detemir (Levemir)
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| Premixed insulin: | 70/30 regular; 70/30 aspart; 75/25 lispro; 50/50
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| Action: Lispro, Aspart | Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 4-6 h
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| Glulisine | Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 6-8 h
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| Action: Regular | Onset of Action 30-60 min; Peak 2-4 h; Duration of Action 6-10 h
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| Action: NPH | Onset of Action 1-2 h; Peak 4-8 h; Duration of Action 10-20 h
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| Action: Glargine | Onset of Action 1-2 h; Peak: None; Duration of Action 24 h
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| Action: Detemir | Onset of Action 1-2 h; Peak 6-8 h; Duration of Action 12-24 h
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| Fx on insulin absorption: Exercise | Strenuous use of injected limb within one hour
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| Fx on insulin absorption: Massage of area | Do not rub site vigorously
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| Fx on insulin absorption: Temperature | Heat increases, cold decreases
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| Fx on insulin absorption: Site of Injection | Abdomen>arms>thigh (R & N only)
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| Fx on insulin absorption: Lipohypertrophy | Delays absorption
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| Fx on insulin absorption: Large doses (>80 units) | Delay onset and duration
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| 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
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| Fx on insulin absorption: Jet injectors | Increase absorption rate
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| Fx on insulin absorption: Certain insulin mixtures | Lente causes loss of rapid acting insulin action
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| Fx on insulin absorption: Large doses (>80 units) | Delay onset and duration
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| Fx on insulin absorption: Suspension form | Proper resuspension needed
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| Use of sliding scale insulin: | should NOT be used as monotherapy
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| Potential for hypoglycemia is increased in: | Acute illness; Erratic food intake; Poor coordination of insulin dosing with meals
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| Hypoglycemia Tx: D50 | IV Dextrose (D50) Admin = most rapid method of alleviating hypoglycemia; appropriate for pts who are unconscious, severely symptomatic, or NPO
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| 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)
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| 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)
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| 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)
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| Troubleshooting high blood sugars | First find underlying cause (insufficient insulin dosing OR other)
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| 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)
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| 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
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| Metabolic syndrome: other major dx criteria | acanthosis nigricans, estd T2DM, central obesity
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| Metabolic syndrome: minor dx criteria | hypercoagulability , PCOS, vascular endothelial dysfunction, CAD, microalbuminuria
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| Whipple triad (hypoglycemia) | hypoglycemic sx (tremor, confusion, sweating, nausea, hunger), low BS, sx resolve when glucose is normal
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| Hypoglycemia | glucose <60; usu 2/2 med use; poss insulinoma
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| Pronounced hyperglycemia with insulin deficiency = | DKA
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| DM: Ocular Complications | Retinopathy; Cataracts; Glaucoma; pts w/ DM need an annual ophthalmologic exam
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| Diabetic Retinopathy: microaneurysms = | Small blow-out swellings of blood vessels
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| DM Retinopathy: Exudates = | Small leaks of fluid from damaged blood vessels
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| DM Retinopathy: hemorrhages | Small bleeds from damaged blood vessels
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| 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
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| Treatment of renal failure due to DM: | renal transplant more promising than dialysis (if patient eligible)
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| Most common complication of DM: | Neuropathy
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| Characterize DM Neuropathy | Distal symmetrical polyneuropathy with loss of motor & sensory function, esp. of long nerves. Mononeuropathy (eg, peripheral or CN)
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| DM Peripheral Neuropathy clinical features | Peripheral: painful diabetic neuropathy with hypersensitivity to light touch.
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| DKA: Dx | Hyperglycemia; Ketonemia; Acidemia
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| Ketones: Why | Insulin def: Inc lipase activity increases breakdown of TGs to glycerol & free fatty acids (= precursors to ketone bodies)
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| DKA mgmt | continuous insulin drip (monitor) (MOST IMPORTANT); Fluids; Potassium; EKG;
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| Somogyi | Hypoglycemia triggers counter-regulatory hormones -> hyperglycemia. Manage insulin to prevent hypoglycemia
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| 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
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| 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
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| 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
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| DM clinical features | Polyuria; Polydipsia; Wt loss; Fatigue; blurred vision; Suscept to infxn; May be asymptomatic, esp Type 2
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| DM: Polyuria occurs when: | serum glu >180 mg/dL (exceeds renal threshold for glu, which leads to increased urinary glu excretion)
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| DM: Glycosuria causes: | osmotic diuresis (ie, polyuria) and hypovolemia
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| Rapid acting insulin: inject when: | within 15 min of meal; as rescue: w/o regard to meals
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| Glulisine (Apidra)(rapid): Dosing: | 15 min prior to meal OR within 20 min after starting a meal
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| Short acting insulin: inject when: | within 30 min of meal; as rescue: w/o regard to meals
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| NPH: typically inject how often: | x2 / day (depending on meal schedule)
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| Detemir is bound to ? and is good out of the fridge for: | bound to albumin; good for 42 days out of refrigerator
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| If change in basal insulin: BID NPH to long-acting: | Reduce TDD by 20%; administer total dose QD
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| 50/50 rule with NPH as basal: | Decrease amt used as bolus by 20%
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| 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)
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| Rule of 1800 formula | 1800 / TDD = x (mg/dL changed by 1 unit insulin) = correction factor
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| Rule of 500: formula | 500 / TDD = x gm CHO covered by 1 unit insulin
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| Which insulins are cloudy? | NPH; mixes
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| Which insulin may be given IV? | Regular
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| T1DM diet recs | 45-65% CHO, 10-35% pro, 25-35% fat; <33 mg/day chol
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| 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.
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| DM Autonomic Neuropathy clinical features | Gastroparesis; hotn; bladder dysfn/UTI; erectile dysfunction
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| Other complications of DM | DM amyotrophy (painful wasting of quad mm in older men). Necrobiosis diabetica (skin), Candida infxn. Osteopenia.
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| HHN state mgmt | Replace fluids & lytes. Insulin required. Abx if underlying infxn
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