Diabetes/thyroid/skin/ER Flashcards
(57 cards)
Somogyi effect
Nocturnal hypoglycemia caused by excessive or insufficient bedtime food intake
Hypoglycemia at 0200-0300 Rebounds with hyperglycemia at 0700
Reduce evening or bedtime insulin dose and provide a small bedtime snack
Dawn phenomenon
Natural circadian release of growth hormones, cortisol and catecholamines which increase insulin resistant during early AM hours
Glucose becomes progressively elevated through the night resulting in elevated glucose levels at 0700
Add or increase the bedtime dose of Long acting insulin and avoid carb heavy bedtime snacks
Glycemic goals
Non ICU-initiate therapy when greater than 180 persistently, target 140-180 (SQ with basal, prandial, and correction)
ICU- target goal 140-180 more stringent of 110-140 (IV)
Special- higher glucose levels may be acceptable in terminally ill patients or those at risk for hypoglycemia
Type one always needed basal insulin even if NPO
IV to SQ transition
Give SQ basal insulin 2 hours before DC IV infusion to prevent rebound hyperglycemia
Monitor glucose
Adjust insulin if needed
Monitor before DC
Predictors of hypoglycemia
Previous episode
Timing between midnight and 6AM
Fasting less than 100 next day can be hypoglycemia
Enteral/parenteral feedings
Check glucose Q 4-6 hours
1 unit insulin per 10-15 grams of carbs in formulas
Continuous- NPH every 8-12 hours with corrected insulin every 6 hours
Bolus- regular or rapid acting with each feeding plus correctional
Nocturnal feeds-NPH insulin with feed initiation
Parental can have insulin, 1 unit per 10 grams of dextrose
Steroid therapy
Hyperglycemia!
Peaks in 4-6 hours
NPH with intermediate acting steroids
Long acting basal for long acting steroids
Peri operative
Goal A1C less than 8% for elective procedures
100-180 within 4 hours of surgery
Hold SGLT2 3-4 days
Hold metformin day of
NPH insulin by half at night time
DKA
Rapid onset
Mild dehydration
Corrected glucose goal 150-200
0.9 % NS at 15-20mo/kg/hr then switch to 0.45% is corrected sodium is normal or high
When glucose goes to 200 switch to D5 -0.45% to prevent hypoglycemia
Insulin- bolus with 0.1 units/kg, continuous 0.1 units/kg/hr
Adjust to decreased glucose by 50-75 mg/dl/hr
When glucose reaches 200 reduce to 0.05-0.1 units/kg/hr and maintain 150-200 until acidosis resolves
If K less than 3.3 good insulin and give K until greater than 3.5
3.3-5.2- add 20-30 meq/L plus IV fluids
If greater than 5.2 monitor
If oh lea than 6.8 give 100 mmol bicarbonate in 400 sterile water plus 20 meq kcl over 2 hours
Phosphate-replace it less than 1 or severe muscle weakness or respiratory issues
HHS
Severe dehydration
Gradual onset
Serum osmolality greater than 320
Corrected glucose goal 250-300
Start with 0.9 NS at 15-20 ml/kg/hr switch to 0.45 % based on sodium levels
Once glucose reaches 300 switch to D5 0.45% to prevent hypoglycemia Insulin
Insulin after fluids
Continuous 0.1 units/kg/hr, no bolus, when reaches 300 decrease to 0.05-1 units/kg/hr maintain 250-300 until osmolality normalizes
Replace K like DKA
No bicarb needed
Replace phos like DKA
How to calculate total daily dose of insulin
Estimate patients TDD based on IV requirements over the last 6-8 hours and multiple by 24 hours
Divide TDD into basal and prandial
50% goes to basal and prandial dividre equally among meals 50% goes to long acting or NPH
Adjust for prandial insulin if eating start rapid acing with broad
Monitor glucose 2-4 hrs
May be conservative with those with no insulin hx or increase if critically ill
Example:
IV insulin rate is 2 units/hour over the last 6 hours
Estimated TDD is 2X24=48 units
Basal- 24 units of glargine daily
Prandial- 24 for all meals, divide by 3 equals 8 units before each meal plus SSI
Administer first glargine 2 hour before stopping IV infusion
Peri operative considerations for AI
Mild- load with hydrocortisone IV 25 my day of operation and resume daily dose next day
Moderate illness or moderate surgery- give total daily dose of hydrocortisone 50-75 mg on day of surgery and then first day post op and then return to normal second day post op
Severe illness or major surgery- give total daily dose or hydrocortisone of 100-150 mg in divided doses start ir day of procedure and 2-3 days post op
Thyroid peri operative
May not need supplementation of thyroid levels if NPO unless greater than 7 days
Chronic steroid use critics
Only if published evidence of benefit
After other failed therapies
Specified objective
Follow response
Administer suffering steroid for sufficient time to achieve response and DC if no longer necessary
Terminate if benefit is not observed, complications arise or benefit not observed
Stop steroids immediately if
Psychosis
Herpes virus induced corneal ulceration
Can reduce if you cannot stop for whatever reason
Monitor for AI taper!
Taper steroids due to AI issues
Prednisone greater than 20 mg daily for 3 weeks
Bedtime dose of prednisone of 5 mg or greater for a few weeks
Any one with Cushing like appearance
Unlikely- those with steroid use less than 3 weeks, alternative day dose at less than 10 my per day
Steroid tapering
Decrease dose by 5-10 mg per day every 1-2 weeks for greater than 40 mg prednisone
Decrease dose by 5 my per day every 1-2 weeks for dose 20-40
Decrease dose by 2.5 per day every 2-3 weeks for dose 10-20
Decreased the dose 1 mg per day every 2-4 weeks for 5-10 mg dose
Decrease dose by 0.5 mg per day every 2-4 weeks for dose 1-5 my every day, can also do alternative day dosing
Addisons disease
Primary-autoimmune
Secondary-disease process, usually ACTH secretion
Tertiary- usually abrupt withdrawal of steroids
Mineralcorticoid usually preserved
Low glucocorticoid
Skin hyper pigmentation
Vetiligo
Fatigue
Poor appetite
N/v/d, weight loss
Syncope and low BP
DX with ATCH stimulation test, CMP (low sodium, high potassium, mild anion gap acidosis, hypoglycemic), CBC, TSH
usually have unexplained shock refractory to fluids or pressors
Dexamethasone or hydrocortisone for Tx
If know DX may need to increase steroid dose due to critical illness
Cushing
Disease or syndrome, syndrome is due to exogenous steroids from like a tumor
24 hr urine for cortisol
Or Dexamethasone test
Thyroid storm
Emergency 🚨
IVF
Anti Adrenergic drugs
PTU/methinazole***
Iodine
Control temperature
Glucocorticoids
Bile acid sequestrants
Myxedema coma
Emergency 🚨
Shock
Low temperature
AMS
Seizures
Hypoxia
TX with thyroid medication IV
May need to be vented
Passive rewarming
SIADH
Low sodium
Low osmolality
Normal or increased plasma volume usually euvolemic
Normal cardiac, renal, thyroid, and no diuretics
Can occur post operative
Normotensive
Urine osmolality greater than 100 in context with hypoosmolality is confirmation
TX with water restriction, hypertonic saline, vasopressin 2 receptor antagonist, loop diuretics
DI
Large volume urine
Greater than 3 L over 24 hours
Urine osmolality less than 300
Central and nephrogenic
Not typically dehydrated
24 hour urine
Urine specific gravity
Plasma ADH
