DM 1 (two)

Question 1

What tx for DM1?

• Used for primary prevention
• Pts w/ incr. risk of CVD
  
  • F: >50
  • M: >60
  • and 1 RF: HTN, HLD, smoking, fam hx of premature dz, albumineria

Answer 1

Acetylsalicylic acid

Question 2

Pts w/ Type 1 DM can get what 2 transplants?

Which one can they NOT get?

Answer 2

• Pancreas transplantation with or without kidney transplantation
• Islet cell transplant
• NOT: pancreatic islet auto-transplantation

Question 3

Type 1 or 2 DM?

• Moderately deficient control of hyperglycemia
• SLIGHT elevation of LDL cholesterol
• Slight elevation of serum triglycerides
• Little/if any change to HDL
• Once hyperglycemia is corrected, –> lipoprotein levels are normal

Answer 3

Type 1

Question 4

Type 1 or 2 DM?

• “Diabetic Dyslipidemia” is characteristic of insulin resistance syndrome
• HIGH serum triglyceride level >300
• LOW HDL cholesterol <30
• Qualitative change in LDL particles, smaller/dense LDL particles are more susceptible to oxidation, renders them more atherogenic.

Answer 4

Type 2

Question 5

What are the 2 neuro/vascular dz complications of diabetes?

Answer 5

• Diabetic foot ulcers
• Gangrene of feet

Question 6

What are the 4 heart disease complications?

Answer 6

• Coronary atherosclerosis
• Myocardial infarction
• Peripheral vascular disease
• Stroke

Question 7

What are the 3 causes of Hypoglycemia?

Answer 7

• Behavioral
• Regulatory issues
• Diabetic complications

Question 8

What are the 3 behavioral causes of Hypoglycemia?

Answer 8

• Too much insulin
• Too much ETOH
• Post-exercise

Question 9

What are the 2 causes of regulatory issues leading to Hypoglycemia?

Answer 9

• Loss of glucagon response
• Sympatho-adrenal responses

Question 10

What are the 2 diabetic complications leading to Hypoglycemia?

Answer 10

• Gastroparesis
• End-stage kidney disease

Question 11

Sxs of what?

• Shaky
• Tachy
• Diaphoretic
• Dizzy
• Anxious
• Hungry
• Blurred vision
• Weak/tired
• HA
• Nervous/upset

Answer 11

Hypoglycemia

Question 12

What meds can induce Hypoglycemia?

Answer 12

◦Sulfonylureas

◦Gatifloxacin & levofloxacin

◦ACE inhibitors

◦Salicylates

◦β-adrenergic blocking agents

◦Quinine

Pentamidine

Question 13

What can these lead to?

• Hypopituitarism
• Addison disease, or myxedema
• Disorders related to liver malfunction, such as acute alcoholism (glycogen depletion) or liver failure
• Gastrointestinal surgery
• Insulinoma

Answer 13

Hypoglycemia

Question 14

What are the 4 ways to prevent/tx hypoglycemia?

Answer 14

• Glucose tablets or Juice
• 15 g of carbs
• Parenteral glucagon emergency kit (1 mg)
• 50 mL of 50% glucose solution by rapid IV infusion

Question 15

What is this effect called?

• Nocturnal hypoglycemia –> leads to surge of counter-regulatory hormones to produce high blood glucose by 7 AM (pre-breakfast hyperglycemia)
• How is it treated?

Answer 15

• Somogyi Effect
• Tx:
  
  • Eliminating dose of intermediate insulin at dinner time
  • Giving intermiediate insulin at a lower dose at bedtime
  • Increase food intake at bed time

Question 16

• Glucose >600
• Osmolarity >320 (normal is 280-295)
  
  • Due to ETOH, antifreeze
• No ion gap (normal)

Answer 16

HHS

Question 17

• 1st symptom that pt has Type 1 DM
• Glucose >300
• Low bicarb
• Ketones / Ketouria
• Acidic pH <7.3

Answer 17

DKA

Question 18

What is the pre-dominating factor in estimating osmolality?

Answer 18

Na

Question 19

If hyperosmolality is not due to high Na, what other 4 things causes it?

Answer 19

Ineffective osmoles (permeable)

• Advanced renal failure (urea)
• Alcohols
  
  • Mannitol, ethanol, glycerol, isopropanol
• Hypertonic Hyponatremia
• Hyperglycemia

(HA HA)

Question 20

Hyperglycemic Hyperosmolar State

• Occurs more commonly in DM1 or DM2?
• Hyperglycemia > ___ mg/dL
• Serum osmolality > ____
• Blood pH of what?

Answer 20

• type 2
• Hyperglycemia: >600
• Osmolality: >310
• pH: >7.3 (no acidosis)

Question 21

What is this?

• Hyperglycemia without ketones
• minimal ketonuria/ketonemia
• NORMAL anion gap (<14)
• Serum bicarb >15

Answer 21

Hyperglycemic Hyperosmolar State

Question 22

Clinical findings of what?

• Profound dehydration (dx/tx delayed until fluid deficit reaches 6-10 L)
• Non-ketotic
• Polydipsia / Polyuria
• Neuro changes (ranging from nystagmus - coma)

Answer 22

HHS

(hyperglycemic hyperosmolar syndrome)

Question 23

Lab results of what condition?

• Plasma glucose: 800 - 2400 mg/dL
• Serum urea nitrogen elevations >100 mg/dL typical

Answer 23

HHS

( hyperglycemic hyperosmolar syndrome)

Question 24

HHS treatment

• FLuids to restore UOP to ___ mL/h or greater
• Hypovolemic sxs (hypotension/oliguria) are treated w/ what?
• 0.45% saline may be utilized for maintenance as body fluids are markedly HYPERosmolar

Answer 24

• 50
• 0.9% normal saline

Question 25

**HHS treatment** * Once blood glucose reaches ____ mg/dL, fluid replacement should include 5% dextrose in either water, 0.45% NS, or 0.9% NS * Maintain glycemia levels of 250-300 mg/dL in order to _reduce the risk of what??_

Answer 25

* 250 * cerebral edema

Question 26

**HHS treatment** * _Treatment w/ what can be delayed??_ * FLuid replacement ALONE can decrease hyperglycemia by correcting the hypovolemia, which can then increase both glomerular filtration & renal excretion of glucose.

Answer 26

**Insulin** can be delayed

Question 27

**HHS tx** * If there is \_\_\_\_, **_start insulin_** rate at 0.05 units/kg/h (bolus not needed) & titrate to lower blood glucose levels by 50-70 mg/dL /hour

Answer 27

Ketonemia

Question 28

HHS tx * If the pt had ketonemia and you started insulin and they are now stabilized (blood glucose fell to around 250), then insulin can be given via what route?

Answer 28

Subcutaneously

Question 29

**HHS tx** * Potassium should be monitored closely * Potassium chloride replacement should proceed liberally, unless what 2 conditions are present???

Answer 29

* CKD * Oliguria

Question 30

**HHS tx** * Severe hypophosphatemia (\<1 mg/dL) during insulin therapy, what is the tx?

Answer 30

Phosphate replacement for ketoacidotic pts

Question 31

**What is this?** * SEVERE insulin deficiency * Marked elevations of glucagon, cortisol, GH, epinephrine, norepinephrine

Answer 31

Diabetic Ketoacidosis (DKA)

Question 32

Most cases of DKA occur in which type of DM?

Answer 32

**Type 1 DM** * already diagnosed pts _or_ may be 1st manifestation of type 1 DM

Question 33

DKA is usually preventable by self monitoring what 2 things?

Answer 33

* Blood **glucose** * Blood/Urine **Ketone** levels

Question 34

**DKA** * What is the most common precipitating factor?? * **Other causes:** insulin omission, pancreatitis, MI, stroke, and drug use

Answer 34

Infection

Question 35

**Causes of what?** _Which one is MC cause?_ * Insulin deficiency (failure to take enough) * Iatrogenic (glucocorticoids) * Infection * Inflammation (pancreatitis, cholecystitis) * Ischemia/infarction (myocardial, cerebral, gut) * Intoxication (EtOH, drugs)

Answer 35

**DKA** | (INFECTION is MC cause)

Question 36

**Sxs of what?** * N/V * Abd pain * Polydipsia / Polyuria * Enuresis * "fruity" acetone breath

Answer 36

DKA

Question 37

**Sxs of what?** * Kussmaul breathing * 2 signs of hypovolemia?? __ & \_\_\_ * AMS * ____ is rare & indicated prolonged period of this condition

Answer 37

**DKA** * _Hypovolemia:_ hypotension & tachycardia * Coma is rare

Question 38

**Acronym for DKA** * KUSSMAL

Answer 38

* K: ketones * U: uremia * S: sepsis * S: salicylates * M: methanol * A: aldehydes * L: lactic acidosis

Question 39

Initial eval of DKA (4)

Answer 39

* ABCs * Mentation * Precipitating factors * Volume status

Question 40

What will a BMP show in pt w/ DKA?

Answer 40

* Glucose, **_Anion gap\*\*\*_**, bicarb * potassium (up or down) * Na (low) - hyponatremia (We want to close the gap!!)

Question 41

What test should be ordered if HCO3 is low in pt w/ DKA?

Answer 41

ABG

Question 42

What lab value may be elevated in pt w/o pancreatitis who is in DKA?

Answer 42

Amylase

Question 43

**DKA or HHS?** * GLucose \>250 * pH \<7.3 * HCO3 \<18 * MODERATE ketonuria or ketonemia

Answer 43

DKA

Question 44

**DKA or HHS?** * Glucose \>600 * pH \>7.3 * HCO3 \>15 * MINIMAL ketonuria & ketonemia

Answer 44

HHS

Question 45

\_\_\_\_\_\_ (increased anion gap) is principally caused by increased production of ketoacids w/ minor contributions from lactic acid / free fatty acids

Answer 45

Metabolic Acidosis

Question 46

Describe the levels of K, phosphate, and Mg

Answer 46

Initially, serum K & phosphate are normal or high, but invariably there is total body depletion of K, phosphate, and Mg.

Question 47

If plasma glucose levels are \<250 = "euglycemic ketoacidosis) caused by what 3 things?

Answer 47

* Fasting/Starvation * ETOH * Pregnancy

Question 48

It is important to prevent the development of hypoglycemia to reduce the likelihood of \_\_\_\_\_, which could result from too rapid decline of blood glucose...

Answer 48

Cerebral Edema\*\*

Question 49

**DKA tx** * Usually require large volume resuscitation!! * IV insulin drip continued till GAP is closed! * Pts may require what type of IVF prior to gap closing? * What 4 levels can be deceiving while BS remains high??

Answer 49

* Dextrose containing IVF * K, phosphorus, Sodium, Mg

Question 50

* DKA patients should be admitted to what hospital department? * What 2 "special" things might they need for management?

Answer 50

* ICU * PICC & ABG

Question 51

**DKA summary:** * DKA usually evolves gradually or rapidly? * What are the early sxs? (4) * As DKA worsens, what symptom worsens? * ABCs * Large IVs (FLUIDS, FLUIDS, FLUIDS)!!

Answer 51

* Rapidly * N/V/ abd pain, hyperventilation * **mental status** worsens as DKA worsens

Question 52

**DKA tx** * Monitoring of what levels is most important?

Answer 52

Electrolytes (K+)