11b - DM Part 2 Flashcards
(96 cards)
1
Q
when does low glucose become hypoglycemia?
A
<54 mg/dL
2
Q
What are some common etiologies of hypoglycemia?
A
Behavioral
Counterregulatory
Complications of DM
3
Q
What behavioral causes lead to hypoglycemia?
A
Insulin dose and carbs not balanced
Drinking ETOH
4
Q
What causes counterregulatory Hypoglycemia?
A
Impaired glucagon response - DM
Cortisol deficiency - addisons
Sympatho-adrenal blunting - lack of awareness
5
Q
SS of hypoglycemia?
A
Sympathetic
- tachycardia
- palpitations
- tremulousness
- sweating
Parasympathetic
- nausea
- hunger
6
Q
What is the function of the exocrine pancreas?
A
Produces digestive enzymes
98-99% of pancreas mass
7
Q
What is the endocrine pancreas?
A
Produces hormones: B cells-insulin A cells - Glucagon D cells - somatostatin F cells - pancreatic polypeotide, Ghrelin
8
Q
Insulin function?
A
Lowers blood glucose
Stimulated by high blood sugar
9
Q
Glucagon function?
A
Raises blood glucose levels
Hepatocytes - convert glycogen
Gluconeogenesis formation
10
Q
What regulates glucagon and insulin?
A
Blood glucose is the most important regulator
11
Q
DM complications
A
Acute:
- hypoglycemia
- DKA
- Hyperglycemic hyperosmolar state
Chronic
- microvascular damage
- macrovascular damage
12
Q
When do neuroglycopenic symptoms appear with hypoglycemia?
A
When blood glucose falls to 50mg/dL
13
Q
Treatment for hypoglycemia
A
Prevention (lol)
Glucose tabs 2-3 tabs
Juice 4-6 oz
Soda 4-6 oz
Follow with complex carbs
14
Q
What is a glucagon kit?
A
A home treatment of severe hypoglycemia
1 ampule of glucagon
Every pt on insulin should have one
15
Q
What will the ER do for hypoglycemia?
A
Establish airway IV glucose (50ml of 50%)
16
Q
If no IV glucose is available what are some other therapies?
A
IM glucagon
If stuporous and no glucagon available: honey, syrup etc in buccal pouch or rectally
17
Q
Is DKA a common occurrence?
A
5-8 episodes/1000 diabetics annually
50-60% of kids will have at least 1
18
Q
What is the mortality rate for DM?
A
5% mortality < 40 yrs old
>20% mortality in the elderly
19
Q
What are some risk factors for DKA with DM1 pts?
A
Infection 30% Lapse in insulin admin 15-41% New onset DM 17-25% Medical illness - 10% Trauma/alcohol/steroids - 10-20% Idiopathic
20
Q
Pathogenesis of DKA?
A
NO insulin -> rapid mobilization of energy stores -> increase flux to live of amino acids for conversion to flucose and ketones
Peripheral utilization of glucose and ketones is reduced
Hyperglycemia and ketonemia occur
21
Q
DKA S/S?
A
Signs: Polyuria, polydipsisa (1-2 days) Fatigue Nausea Vomiting Stupor/coma Hypothermia
Symptoms: Dehydration Kussmaul respirations Fruity breath HOTN Tachycardia
22
Q
What will the lab find on DKA pts?
A
Hyperglycemia 350-900 Serum ketones Glucosuria 4+ Strong ketonuria low pH (6.9-7.2) Low bicarb (5-15 mEq/L)
23
Q
Less frequent lab findings with DKA?
A
Hyperkalemia Hyponatremia H Amylase H creatinine H temp Leukocytosis w L shift
24
Q
What causes ketoacidemia?
A
Lack of insulin + H GH, catecolamines, glucagon lead to:
Lypolysis from adipose tissue -> release of FFAs -> ketone bodies in liver
25
Best way to treat DKA?
Prevention
26
What do DM-1 pts need to do when they get sick?
Sick day guidelines
1. Test urine ketones q 2-4 hrs
2. Test blood gluose q 4+ times a day
3. Continue to take insulin and eat (if possible)
27
DKA treatment
1. Therapeutic flow sheet (bunch of vitals and labs)
2. Fluids: 4-5L
3. Insulin replacement (immediate post fluids)
4. potassium
5. Sodium bicarb
6. Phosphate
7. ABx (if infected)
28
Fluid therapy for DKA
1 L/hr x 1-2 hrs
After 2 L give 300-400ml/hr
When glucose is <250 give 5% glucose to keep serum glucose at 250-300
29
BOLUS fluid for DKA?
Nope, too much (>5L in 8 hrs) cause ARDS and cerebral edema
30
Why potassium?
Polyuria and vomiting lowers levels
Acidosis: shift of K from cells to extracellular space
Once acidosis gets better it goes back leaving them hypokalemic
31
Who gets sodium bicarb?
We only use this with pH < 7 because it may actually be harmful
32
What is the 2nd MC form of hyperglycemic coma?
Hyperglycemic hyperosmolic state
33
What is hyperglycemic hyperosmolar state?
Severe hyperglycemia in absence of significant ketosis
- mild or undiagnosed DM
- CHF/CKD
- drugs
34
What is the mortality rate of hyperglycemic hyperosmolar state?
High mortality due to insidious organ dysfunction and delayed diagnosis
10 x mortality of DKA
35
Pathogenesis of hyperglycemica hyperomolar state?
Partial or relative insulin deficiency reduces glucose utilization by muscle, fat and liver, while promoting hyperglucagonemia and increasing hepatic glucose output
36
S/S of hyperglycemia hyperosmolar state?
Insidious onset:
- polyuria
- polydipsia
- weakness
- lethargy and confusion -> coma
37
Hyperglycemia hyperosmolar state respirations?
Absence of kussmaul respirations
38
What labs will you see with hyperglycemic hyperosmolar state?
```
Severe hyperglycemia 600-2400!!!
Hyponatremia
NO ketosis
NO acidosis
Prerenal azotemia - BUN > 100 mg/dL
```
39
Tx of hyperglycemic hyperosmolar state
1. Fluid replacement
2. Insulin
3. Potassium
4. Phosphate
Basically same as DKA
40
How much insulin is needed for hyperglycemic hyperosmolar state?
Less than DKA
Initial .15 unit/kg
Then
Infusion 1-2 u/hr to lower glucose by 50-70mg/dL/hr
41
Who gets DKA and who gets Hyperglycemia Hyperosmolic state?
DKA is DM 1
| HHS is DM 2
42
Vascular complications of DM-1
End stage renal disease (40%)
Blindness (retinopathy and detachment)
Diabetic neuropathy
43
DM 1 major cause of death?
Complications from end stage renal disease
44
Vascular complications of DM-2?
End stage renal disease 20%
Blindness caused by macular edema/ischemia
Diabetic neuropathy
45
major cause of death in DM-2?
Macrovascular disease leading to MI and stroke
46
Cigarette effect on DM 1 and 2 complications?
Adds significantly to the risk of both microvascular and macrovascular complications in all diabetic patients
47
Chronic DM complications?
```
A. Ocular complications
B. Diabetic neuropathy
C. Diabetic neuropathy
D. Cardiovascular complications
E. Skin/mucous membrane complications
```
48
What types of ocular complications do Diabetics get?
Diabetic cataracts
Glaucoma
Diabetic retinopathy
49
What are the categories/stages of diabetic retinopathy?
Nonproliferative (background)
| Proliferative (malignant)
50
What causes nonproliferative retinopathy?
Microaneurysms
Hemorrhages
Exudates
Retinal edema
Cotton wool spots are seen pre proliferative
51
What causes proliferative retinopathy?
Newly formed vessels from chronic ishemia + macular edema
Increased risk of retinal detachment
52
Treatment for proliferative (malignant) retinopathy?
Photocoagulation (laser)
| Bevacizumab (avastin) - antivascular injection into eye - stops new growth
53
S/S of diabetic retinopathy?
```
Acute loss of visual acuity
Diplopia
Fluctuating visual changes
Floating spots
Flashing lights
ocular pain
```
54
When do DM pts need to get vision screening?
DM -1: 3-5 yrs after diagnosis then annually
DM -2: at diagnosis, then annually
55
What % of renal disease pts are diabetics?
30%
56
Manifestations of DM renal disease?
Microalbuminuria (early)
Proteinuria
Urea and creatine accumulation in blood
57
Will a urine dipstick screen for microalbuminuria?
Nope, requires an overnight urine collection
58
What is the albumin/creatinine ratio?
Morning spot albumin: creatinine ratio test
Requires 2-3 + tests in 3-6 mo for diagnosis
59
DM 1 and 2 screening for microalbuminuria?
DM 1 5 yrs post diagnosis then annually
DM 2 at diagnosis then annually
60
How do we treat microalbuminuria?
ACEI (prils):
ARBs (sartans):
Low protein diet
Monitor alb:cr ratio q 6 mos
61
What is seen with progressive diabetic nepropathy?
Proteinuria + hypoalbuminemia, edema and increased LDL
Progressive azotemia
HTN and accelerated CVD
62
Tx for progressive diabetic nephropathy?
BP control (captopril 50% reduction in death/transplant)
Protein sparing diet
Renal transplant
Dialysis is of limited value
63
How fast does kidney failure happen with DM once it starts?
W/in 5 yrs 50% of pts will have 50% decline in GFR
3-4 years after that 50% will have ESRD and required a new kidney
64
Should DM pts get contrast radiographic studies?
Think twice
Can do if needed but hydrate them really well
65
What is the MC diabetic peripheral neuropathy?
Distal symmetric polyneuropathy
66
Types of peripheral neuropathy?
A. Distal symmetric polyneuropathy
B. Isolated peripheral neuropathy
C. Painful diabetic neuropathy
67
Types of diabetic neuropathies?q
1. Peripheral neuropathy
| 2. Autonomic neuropathy
68
What is distal symmetric polyneuropathy?
Bilateral symmetrical nerve involvement
“Glove and stocking”
69
Is distal symmetric polyneuropathy sensory or motor
Can be both but sensory is always there
- initially dullness of vibration, pain, temp
-Pain ranging from mild - incapacitation
-
70
What is the problem for distal symmetric polyneuropathy with decreased pain?
Decreased pain threshold -> repetitive stress -> callouses and ulcerations
71
What is charcot foot arthropathy?
- Rocker bottom deformity
| - Joint subluxation and periarticular fx
72
What do pts need to do to avoid distal symmetric polynephropathy problems?
```
Early detection
-distal reflexes
-distal vibration senses
- distal light touch
Foot wear and daily inspections
Tight glucose control
```
73
Is isolated peripheral neuropathy reversible?
Yes it is acute and reversible
| Usually in 6-12 weeks
74
What causes isolated peripheral neuropathy?
Vascular ischemia or traumatic damage
Femoral and cranial neves MC
75
What is painful diabetic neuropathy?
Hypersensitivity to light touch
| Sever burning pain at night
76
Tx for painful diabetic neuroopathy?
TCAs - amitriptyline or desipramine
Gabapentin or pregabalin
Duloxetine (SNRI)
Capsaicin cream
77
What is autonomic neuropathy?
Neuropathy of autonomic system
Affects:
- BP and pulse
- Gi tract
- bladder function
- ED
78
What is the MC autonomic neuropathy?
GI tract
79
Who gets autonomic neuropathy?
Usually its pts with a long hx of DM
80
GI tract autonomic neuropathy presentations
Gastroparesis
Gastric dysmotility
Constipation
Diarrhea
81
GI tract autonomic neuropathy tx?
Treat the symptoms as normal
82
What are ED therapies for autonomic neuropathy?
Meds: PDE5 inhibitors
Mechanical therapy (pumps)
Surgery (prostheses)
Big difference between this and normal ED is that it is often persistent
83
What is the leading cause of death for DM2?
Myocardial infarction
84
DM cardiovascular complications
```
PVD:
Ischemia of lower extremities
Erectile dysfunction
Intestinal angina
Gangrene of feetq
```
85
BP recommendations for DM pts?
140/90
86
DM PVD management?
```
BP < 140/90
Low dose aspirin
Tobacco cessation
Lipid control
Exercise
```
87
Diabetes amputations?
Dm causes 1 million amputations each year
88
Prevention of diabetic foot problems?
Comprehensive foot exam annually:
Visual: skin, tissue, shoes, biomechanics
Palpation: pulses
Sensation: monofilament, vibration, pinprick, ankle
89
Foot problems are categorized as low risk or at risk, what is at risk?
```
Loss of protective sensation
absent pedal pulses,
foot deformity,
hx of foot ulcer,
prior amputation,
smokers,
hx of retinopathy,
neuropathy,
receiving anticoagulants
Cannot see/reach feet
```
90
What do you do with at risk vs low risk pts?
At risk: refer to podiatry
Low risk: counsel/educate
91
Can DM pts wear sandals?
I mean its a free country but they shouldn’t if they like keeping their feet
92
Skin complications that are common with DM?
```
Insulin hypertropy/atrophy
Candida (thrush)
Xanthelasma
Vitiligo
Necrobiosis lipidica diabeticorum
Dupytrens contracture
```
93
Consults for DM pts
```
Diabetic education class
Dietary consult
Optometry
Podiatry
```
94
Fasting glucose and HbA1C goals for diabetics?
Glucose: 110-120
| HbA1C <7.0% (6.5 if otherwise healthy)
95
Annual things with your DM pts?
```
BP/pulse/height/wt (every visit)
Foot exam
Lipid profile
Fasting glucose
HbA1C 2-4 times/yr
Microalbumin
Pneumovax/flu shot
```
96
What kind of band plays snappy music?
A rubber bad
