Diabetic Management

Question 1

Which is the first drug of choice in patients with diabetes mellitus?

a. Sulfonylureas
b. Biguanides
c. Insulin
d. Meglitinides

Answer 1

B. Biguanides

Question 2

What type of patients should you avoid Biguanides in? (select all that apply):
A. Cardiac disease
B. Lactic acidosis
C. Acute kidney injury
E. COPD
F. Gastrointestinal intolerance
F. Acute hepatic disease

Answer 2

B. Lactic acidosis

C. Acute kidney injury

F. Gastrointestinal intolerance

F. Acute hepatic disease

Question 3

What are two rare adverse effects that can occur with Biguanides? (select 2)

A. Weight loss
B. GI discomfort
C. Hypoglycemia
E. Malaise
F. Metformin-associated lactic acidosis
G. Drowsiness
H. Megaloblastic anemia

Answer 3

F. Metformin-associated lactic acidosis

H. Megaloblastic anemia

Question 4

During the pre-operative assessment on a trauma patient who suffered a broken femur during an MVC, the CRNA looks at the patient’s home medication list. The CRNA notices the patient takes the oral medication Glyburide and knows which of the following would be a contraindication for the patient to take this medication?

a. Obesity
b. Sulfa allergy
c. Type 2 diabetes
d. Atrial fibrillation

Answer 4

b. Sulfa allergy

Question 5

True or false. Sulfonylureas are the oldest class of oral diabetic agents?

Answer 5

True

Question 6

Which of the following are considered to be risk factors for sulfonylurea induced hypoglycemia? (choose 2)

A. Age greater than 60 years old
B. Hypertension
C. Age less than 40 years old
D. Given concurrently with Warfarin

Answer 6

A. Age greater than 60 years old

D. Given concurrently with Warfarin

Question 7

True or False: Meglitinides should be taken after meals as to prevent hypoglycemia

Answer 7

False: they should be taken 15-30 min before

Question 8

Which ion channel does Meglitinides inhibit to ultimately release insulin?

A. Sodium ion Channels
B. Chloride ion channels
C. ATP-sensitive potassium channels
D. Pancreatic Alpha cells

Answer 8

C. ATP-sensitive potassium channels

Question 9

When should Meglitinides be discontinued for a minor surgery?

A. Discontinue 48 hours prior to
B. Discontinue day before
C. Discontinue morning of surgery
D. Discontinue night of surgery

Answer 9

C. Discontinue morning of surgery

Question 10

True or False: Patient taking Rosiglitazone comes in surgery, you expect the dose of your Versed to be increased by 26%?

Answer 10

False. It would be decreased

Question 11

Which medication should you avoid in a patient who has a known history of cardiovascular disease and past MI?

a) Pioglitazone
b) Insulin
c) Rosiglitazone
d) Metformin

Answer 11

c) Rosiglitazone

Question 12

Which of the following are side effects of Thiazolidinediones ? (Select all that apply)

a) Bladder cancer
b) Stroke
c) Bone loss
d) Weight Gain
e) V-Tach

Answer 12

a) Bladder cancer
c) Bone loss
d) Weight Gain

Question 13

During your preop evaluation you ask your patient what medications they take for their Type 2 DM. They say they don’t know, but it is a shot they take once a week that also helps with weight loss. You, as the anesthesia provider, should understand that the patient is taking:

a. Sulfonylureas
b. Insulin
c. GLP-1 agonist
d. DDP-4 inhibitor

Answer 13

C. GLP-1 agonist

Question 14

Which type 2 diabetes medication are known as incretin mimetics because they increase insulin through the incretin effect?

a. Biguanides
b. SGLT2 inhibitors
c. Alpha glucosidase inhibitors
d. GLP-1 agonists

Answer 14

d. GLP-1 agonists

Question 15

Your patient is on a GLP-1 agonists and knowing the mechanism of action you understand you should not restart this post-operatively in your patient who has undergone:

a. Exploratory laparotomy
b. Cystoscopy
c. Aortic valve replacement
d. Total knee arthroplasty

Answer 15

a. Exploratory laparotomy

Question 16

The incretin hormone GLP-1 is broken down by DPP. What are the two functional roles of GLP-1? (Select 2)

a. Stimulates the release of insulin from pancreatic Beta cells in response to increased plasma glucose
b. Stimulates the release of insulin from pancreatic Beta cells in response to decrease plasma insulin
c. Impedes release of glucagon from the alpha cells in the islet of Langerhans
d. Stimulates decreased uptake of glucose by muscle and fat

Answer 16

a. Stimulates the release of insulin from pancreatic Beta cells in response to increased plasma glucose
c. Impedes release of glucagon from the alpha cells in the islet of Langerhans

Question 17

What is a major side effect of an A.G.I.? (select all that apply)

a. Hypoglycemia
b. Flatulence
c. Heart burn
d. Kidney failure

Answer 17

a. Hypoglycemia

b. Flatulence

Question 18

What is a primary mechanism of action of A.G.I?

a. Stops the absorption of carbohydrates by inhibiting the enzymes that convert complex carbohydrates into simple
b. Blocks Na/K pump
c. Enhances cytochrome P450 to reduce the amount of sugar being absorbed in the bloodstream
d. Blocks the production of renin which increases aldosterone to allow polysaccharides to be broken down into disaccharides which is readily absorbed back into the blood

Answer 18

a. Stops the absorption of carbohydrates by inhibiting the enzymes that convert complex carbohydrates into simple

Question 19

What should an anesthetist investigate when a patient state they take A.G.I?

a. Last dose
b. Combination therapy
c. A1C and blood glucose monitoring
d. All of the above

Answer 19

d. All of the above

Question 20

1. Which of the following are directly caused by SGLT-2 Inhibitors?

a. Cause weight gain (~5 lbs)
b. Hypotension
c. Euglycemic DKA
d. Decrease risk of osteoporosis

Answer 20

C. Euglycemic DKA

Question 21

Which of the following demonstrates the nurse anesthesia resident understands the appropriate care-plan for a patient taking SGLT-2 inhibitors? SELECT 3:

a. Ensure the patient stops taking their SGLT-2 medication a week prior to surgery
b. Prepare to give extra fluids during the procedure for hypovolemia
c. Request a full CBC and BMP prior to the procedure
d. Ensure placement of an NG tube that will be left after surgery due to aspiration risk
e. Monitor for increased pulse pressure variation in the SpO2 waveform
f. Have ephedrine or phenylephrine ready prior to induction in anticipation for potential hemodynamic changes

Answer 21

b. Prepare to give extra fluids during the procedure for hypovolemia
e. Monitor for increased pulse pressure variation in the SpO2 waveform
f. Have ephedrine or phenylephrine ready prior to induction in anticipation for potential hemodynamic changes

Question 22

True or false: SGLT-2 inhibitors are one of the only oral antihyperglycemic medications approved to treat both type I and type 2 diabetes.

Answer 22

False

Question 23

Name factors that can stimulate insulin production? (7)

Answer 23

1. Glucose
2. Mannose
3. Fructose
4. Amino acids
5. GI hormones
6. AcH
7. B-adrenergic stimulation

Question 24

​1 unit of IV regular insulin can decrease blood glucose by how much mg/dL?

A.) 10
B.) 25-30 mg/dL
C.) 60-70
D.) 50

Answer 24

25-30 mg/dL

Question 25

What is the blood glucose goal in pre-op? | How about intra-op?

Answer 25

Pre-op = <200; | Intra- op = 120-180

Question 26

How do you prepare an insulin drip? And at what is your ideal starting rate?

Answer 26

Mix 100 units of regular insulin in 100mL of normal saline (1 unit/mL) start with 0.02 unit/kg/H (1.4 units/h in a 70kg patient)*

Question 27

What is the onset, duration, and peak of Regular insulin? A.) onset 30 min, peak 2-4 hours, duration 6-8 B.) onset 5 minutes, peak 30 minutes, duration 1 hour C.) onset 1 hour, peak 2 hours, duration one day D.)onset 30 seconds, peak 5 minutes, duration 10 minutes

Answer 27

A.) Regular: onset 30 min, peak 2-4 hours, duration 6-8 | Lispro: onset: 5-15 min, peak 45-75 min, duration 2-4 hours

Question 28

Where is the absorption of insulin when administered subcutaneously least variable?

Answer 28

The abdomen

Question 29

What is it that NPH is conjugated in that delays its absorption, thus giving it its intermediate affect? a. Protamine. b. Heparin c. Heart burn d. Being an SRNA

Answer 29

a. Protamine.

Question 30

Protamine containing insulins must be administered slowly? T/F

Answer 30

True

Question 31

Upon reviewing your patient’s chart prior to surgery, you notice that the patient is a type I diabetic that normally takes a morning dose of long-acting insulin. Upon speaking with the patient, the patient states they held all of their morning insulin medications just to be safe. Which of the following choices below is the most correct option regarding Type I diabetics that take long-acting insulin medications to avoid diabetic ketoacidosis? a. Type I diabetics should administer approximately 75% of their normal morning long-acting insulin medication the morning of surgery. b. Type I diabetics should hold all insulin injections the morning of surgery. c. Type I diabetics should administer all of their normal morning doses of long-acting insulin medication the morning of surgery. d. Patients with Type I diabetes mellitus should administer about 50% of their usual long-acting insulin medication the morning of surgery.

Answer 31

Answer: D Patients with Type I diabetes mellitus should administer about 50% of their usual long-acting insulin medication the morning of surgery. Rationale: Patients with type 1 diabetes mellitus should take a small amount, 1/3 to 1/2, of their usual morning dose of intermediate-acting or long-acting insulin to avoid diabetic ketoacidosis.

Question 32

Which of the following medication classes below may increase the duration of action of insulin and may have a direct hypoglycemic effect when administered with long-acting insulin? a. Salicylates b. Corticosteroids c. Sympathomimetic agents d. Diuretics

Answer 32

Answer: A – Salicylates Certain oral antidiabetic medications, pramlintide acetate, angiotensin converting enzyme (ACE) inhibitors, disopyramide, fibrates, fluoxetine, monoamine oxidase (MAO) inhibitors, propoxyphene, pentoxifylline, salicylates, somatostatin analogs, and sulfonamide antibiotics can increase the duration of action of insulin and may have a direct hypoglycemic effect.

Question 33

The night before surgery in a patient who manages their blood sugar with short and long- acting insulin, how should they tailor their dosing? a. DC the meds the night prior b. Reduce dose by 50% c. Take short acting as scheduled and reduce long acting by 20% d. Increase the long-acting dose by 20% and omit the short acting

Answer 33

c. Take short acting as scheduled and reduce long acting by 20%

Question 34

Your patient a type two diabetic presents with a fasting blood glucose of 320mg/dl the morning of surgery @ 0630. The patient is scheduled to have a L BKA at 1100. What should be your next action as an anesthesia provider? a. Proceed with the surgery as planned b. Alert the surgeon and administer ordered insulin amount with scheduled rechecks c. Cancel the surgery d. Administer long-acting insulin since the surgery is over four hours away

Answer 34

b. Alert the surgeon and administer ordered insulin amount with scheduled rechecks

Question 35

A type one diabetic morning of surgery states that they stopped their insulin pump 48 hrs prior to the surgery because of abdominal pain. The patient’s fast blood glucose is >600, ABG PH is 7.28, the patient is tachycardic, BP is 86/40, oxygen saturation is 92% on room air. As an anesthesia provider what would be the appropriate next step? Select all that apply a. Alert the surgeon of the elevated glucose b. Administer IV insulin gtt per culture protocol with loading dose of short acting ​​​insulin c. Check blood glucose every hour at minimum d. Postpone the procedure. e. Place a bipap on the patient f. Apply 02 NC

Answer 35

a. Alert the surgeon of the elevated glucose b. Administer IV insulin gtt per culture protocol with loading dose of short acting ​​​insulin c. Check blood glucose every hour at minimum d. Postpone the procedure. f. Apply 02 NC

Question 36

For every _____ increase in glucose during intraoperative period, adverse outcome risk increases by 30%

Answer 36

20%

Question 37

Average glucose goal for patients intraoperatively? A.) 110 -150 B.) 100 - 140 C.) 90 - 120 D.) 120 - 180

Answer 37

D.) 120 - 180

Question 38

How often will you check glucose level for patients who have a high insulin requirement or during a CABG? ​a. Every 2 hours b. Every 1 hour c. Every 30 minutes d. Every 90 minutes

Answer 38

c. Every 30 minutes

Question 39

Which of the following triggers the release of insulin? Select 2 a. Hyperglycemia b. Increased parasympathetic activity c. Hypercalcemia d. Hypomagnesium

Answer 39

a. Hyperglycemia | b. Increased parasympathetic activity

Question 40

A patient who you have just delivered to PACU is reported to have a BG of 190. The best response from the anesthesia provider is which of the following? a. ) The patient has an elevated blood glucose due to the surgical stress response, it should return to normal in the next 24 hours b. ) Research has shown that as long as the blood glucose is under 200 the outcomes for patients are no different. c. ) The patient needs to be treated with insulin to improve the post-op outcome. d. ) The patients should be placed on an insulin drip to bring their blood glucose to 80-100mg/dl

Answer 40

c.) The patient needs to be treated with insulin to improve the post-op outcome.

Question 41

What is the average daily use of insulin in a non-diabetic patient? a. ) 50-100 Units b. ) 200 Units c. ) 30-50 Units d. ) 20-30 Units

Answer 41

c.) 30-50 Units

Question 42

Which of the following should be considered in the decision to continue an insulin pump during the operative period? Select all that apply a. Patient position during operation b. Length of procedure c. History of PONV d. Need for intra-operative defibrillation

Answer 42

a. Patient position during operation b. Length of procedure d. Need for intra-operative defibrillation

Question 43

During an anesthetic, the patient with an insulin pump in place has a glucose reading of 550. What is the best course of action?​ a. Bolus 12 units of IV regular insulin and leave the insulin pump in place b. Continue to monitor, this is an expected neuroendocrine response to surgical stimulation c. Discontinue the insulin pump and initiate an IV regular insulin drip for glucose control d. Increase the patient's D5LR infusion rate for optimal hydration

Answer 43

c. Discontinue the insulin pump and initiate an IV regular insulin drip for glucose control