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?

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

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

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

DM 1 (two) Flashcards by Shea Green

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

Acetylsalicylic acid

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

Which one can they NOT get?

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

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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

Type 1

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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.

Type 2

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

Diabetic foot ulcers
Gangrene of feet

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What are the 4 heart disease complications?

Coronary atherosclerosis
Myocardial infarction
Peripheral vascular disease
Stroke

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What are the 3 causes of Hypoglycemia?

Behavioral
Regulatory issues
Diabetic complications

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What are the 3 behavioral causes of Hypoglycemia?

Too much insulin
Too much ETOH
Post-exercise

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

Loss of glucagon response
Sympatho-adrenal responses

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What are the 2 diabetic complications leading to Hypoglycemia?

Gastroparesis
End-stage kidney disease

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Sxs of what?

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

Hypoglycemia

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What meds can induce Hypoglycemia?

◦Sulfonylureas

◦Gatifloxacin & levofloxacin

◦ACE inhibitors

◦Salicylates

◦β-adrenergic blocking agents

◦Quinine

Pentamidine

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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

Hypoglycemia

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What are the 4 ways to prevent/tx hypoglycemia?

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

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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?

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

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

HHS

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

DKA

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What is the pre-dominating factor in estimating osmolality?

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

Ineffective osmoles (permeable)

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

(HA HA)

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Hyperglycemic Hyperosmolar State

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

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

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What is this?

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

Hyperglycemic Hyperosmolar State

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)

HHS

(hyperglycemic hyperosmolar syndrome)

Lab results of what condition?

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

HHS

( hyperglycemic hyperosmolar syndrome)

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

50
0.9% normal saline

**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??_

* 250 * cerebral edema

**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.

**Insulin** can be delayed

**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

Ketonemia

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?

Subcutaneously

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

* CKD * Oliguria

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

Phosphate replacement for ketoacidotic pts

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

Diabetic Ketoacidosis (DKA)

Most cases of DKA occur in which type of DM?

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

DKA is usually preventable by self monitoring what 2 things?

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

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

Infection

**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)

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

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

DKA

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

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

**Acronym for DKA** * KUSSMAL

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

Initial eval of DKA (4)

* ABCs * Mentation * Precipitating factors * Volume status

What will a BMP show in pt w/ DKA?

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

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

ABG

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

Amylase

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

DKA

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

HHS

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

Metabolic Acidosis

Describe the levels of K, phosphate, and Mg

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

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

* Fasting/Starvation * ETOH * Pregnancy

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

Cerebral Edema\*\*

**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??

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

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

* ICU * PICC & ABG

**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)!!

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

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

Electrolytes (K+)