Where is the Pancreas located?
Back of Abdomen behind the Stomach
What are the two main hormones that the Pancreas secrete?
Insulin & Glucagon - opposite functions
How does the body raise its blood sugar?
Low blood sugar –> Pancreas secretes Glucagon –> Converts Glycogen to Glucose in the Liver –> Releases Glucose into Blood
How does the body lower its blood sugar?
High blood sugar –> Pancreas secretes Insulin –> Converts Glucose to Glycogen in Liver & Stimulates Glucose uptake
What cell type makes of the majority of the Pancreas
Acini - exocrine function - secretes digestive juices into duodenum
Which cells make up the Islet of Langerhans of the Pancreas?
- Alpha Cells - Glucagon
- Beta Cells - Insulin
- Delta Cells - Somatostatin
- Pancreatic Polypeptide Cells
What does Insulin do to Carbs & Amino Acids?
Store Carbs as Glycogen in Muscle & Liver
Excess Carbs converted to Fats & stored in Adipose
Promotes uptake of Amino Acids & converts to Protein
What stimulates Insulin secretion?
High Blood Glucose
Amino Acids
Beta-Keto Acids
Glucagon
Acetylcholine
Intestinal Hormones
Beta Agonists
What inhibits Insulin Secretion?
Low Blood Glucose
Fasting
Glucagon
Cortisol
Catecholamines
Growth Hormone
Somatostatin
What is the Half Life of Insulin
Unbound - 6 to 7 minutes
Which enzyme degrades unused Insulin?
Insulinase
How do Neurons, Muscle, and Adipose cells react to Insulin?
Muscle & Adipose - Glucose uptake via Endocytosis
Neurons - Permeable to glucose
At what blood sugar does Insulin start to release?
100 mg/dL w/ max response at 400-600 mg/dL
Plasma insulin levels can increase by 10x after a meal
What are the Anabolic effects of Insulin?
↑Glycogenesis
Inhibits Glycogenolysis
Inhibits Gluconeogenesis
Traps Glucose for Later Use
↑Protein Synthesis
↑Liver Uptake, Storage, and Use of Glucose
↑Lipogenesis
Insulin facilitates entry of glucose into cells of all tissue EXCEPT which?
Brain
Kidney Tubules
RBCs
How does Insulin effect fatty acid when fed vs fasting?
Fed: Insulin suppresses fatty acid mobilization (glucose already available)
Fasting: Insulin releases free fatty acid into circulation for fuel
What are produced when Insulin Levels are Low during Fasting?
Ketone Bodies
What are Glucagon’s Catabolic Effects?
Activates enzymes for Glycogenolysis
↑Gluconeogenesis
↑Lipolysis & Ketogenesis
↑Proteolysis & Flow of Amino acids from Muscle to Liver for Gluconeogenesis
↑Heart Strength & Blood Flow
↑Bile Secretion
Inhibits Gastric Acid Secretion
What stimulates the release of Glucagon?
Fasting Hypoglycemia
Amino Acids
Beta-Adrenergic Stimulation
Exercise
Cholecystokinin
Gastrin
Cortisol
Surgery
What Inhibits Glucagon release?
High Glucose
Somatostatin
Free Fatty Acids
Ketones
Insulin
What is Diabetes Mellitus?
Syndrome of impaired Carb, Fat, and Protein metabolism
What is the difference between Type I & Type II Diabetes?
Type I
Lack of Insulin Secretion
Effects Any Age, Thin bodied, and DKA is often
Type II
Decreased Insulin Sensitivity or Insulin Resistance
Effects Obese Adults, More Prevalent, and DKA is rare
What would you expect when over 180mg/dL of Glucose is reabsorbed by the Kidney?
Osmotic Diuresis
Loss of Na, K, & Glucose in Urine
Hypovolemia, Hypotension & Dehydration
Polyuria
Polydipsia & Polyphagia
What are the Acute Symptoms of Diabetes?
Polyuria
Polydipsia
Polyphagia
Irritability
Confusion
Impaired Vision
What are Chronic symptoms of Diabetes?
Infection
Non-Alcoholic Fatty Liver Disease
Macrovascular Disease
(CAD, PAD, AMI, CHF, CVA)
Microvascular Disease
(Nephropathy, Retinopathy, Neuropathy)
What is the cause of Type I Diabetes?
Destruction of Beta Islet Cells d/t Viral Infections or Autoimmune Disorders
Plasma Insulin Levels are normally ______ in Type II Diabetes
Plasma Insulin Levels are normally elevated in Type II Diabetes, but still not enough for glucose regulation
What are the 4 ways to Diagnose Diabetes?
- A1c > 6.5%
- Fasting Glucose > 126 mg/dL
- Oral Glucose Tolerance after 2 hrs > 200 mg/dL
- Random Glucose > 200 mg/dL w/ hyperglycemia symptoms
What does a Hgb A1c reflect?
Average Blood Sugar over 3 Months
Normal: 4 - 5.6%
How does Glucose Control help during the Perioperative Period?
Insulin inhibits inflammatory growth factors relating to MI
Insulin Improves Cardiac Contractility
Better Patient Outcomes
How should Diabetic Meds be managed PeriOperatively?
Hold oral meds day of surgery
Continue Basal Insulin for Type I Diabetics
Continue Insulin Pump or Change to IV Insulin
What is the Target A1c in regards to taking Oral Hypoglycemics?
A1c < 8%
What is the First Line Oral Medication for Diabetes?
Biguanides - Metformin
↓Liver Glucose Production
↑Insulin Uptake
What are the side effects of Metformin (Glucophage)?
Lacic Acidosis, especially for Liver/Kidney/CHF patients
What Diabetic medication Increases Insulin Secretion?
Sulfonylureas -
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide (Diabeta)
Meglitinides
Repaglinide (Prandin)
Both classes carry Hypoglycemia risks
What do Thiazolidinediones do?
Decrease Liver Glucose Production & Insulin Resistance
Drugs ending in “-tazone”
Pioglitazone (Actos)
How is a patient’s Insulin Regimen managed PeriOperatively?
Give 1/2 dose of Long Acting
&
Hold Short Acting on day of surgery
What can be added to Insulin to prolong their effects?
Protamine
Careful when giving it to reverse Heparin
What are the Rapid Acting Insulins?
Aspart (Novolog)
Lispro (Humalog)
Glulisine (Apidra)
Regular (Humulin/Novalin R)
What is the Onset, Peak, and Duration of Regular Insulin?
Onset: 30-60 min
Peak: 2-4 hrs
Duration: 6-8 hrs
All other Rapids are 15 min, 1 hr, and 3-4 hrs respectively
Which Insulin type is Intermediate-Acting?
NPH
Onset: 1-3 hrs
Peak: 6-8 hrs
Duration: 12-16 hrs
What are the Long Acting Insulins?
Detemir (Levemir)
Glargine (Lantus)
Onset: 1 hr and lasts from 6 - 34 hrs
What is the pathophysiology of DKA?
Dehydration
Acidosis
Electrolyte Depletion, especially Potassium
Accelerated Protein Breakdown
↑Fatty Acids
What are symptoms of DKA?
N/V
Polyuria
Polyphagia
Anorexia
Kussmaul Breathing
Acetone Halitosis
What is a patient DKA’s level of consciousness related to?
Osmolality, NOT Acidosis
How is DKA treated?
Lots of Fluids
Replace Lytes
Insulin
What is Nonketotic Hyperosmolar State?
Same as DKA, but with really high blood sugar, no ketoacidosis, and higher motality
What are the symptoms of Nonketotic Hyperosmolar State?
Clots d/t Thick Blood
Neuro Signs
Confusion
Seizure
Coma
How is Nonketotic Hyperosmolar State treated?
Aggressive Fluids, then add sugar at BG of 250
Replace Kphos & Insulin if needed
What is the body’s early response to Hypoglycemia?
Liver Glycogen Breakdown
What is the body’s Late response to Hypoglycemia?
Sympathetic Stimulation & Epi Release
What is the body’s Very Late response to Hypoglycemia?
Growth Hormone & Cortisol Secretion
What is Insulinoma?
Beta Cell Adenoma
Causes Insulin Shock = coma w/ BG < 20 mg/dL
Treat w/ Glucagon & Epinephrine
At what Blood Glucose level will Hypoglycemic Shock happen?
20 - 50 mg/dL
Fainting, Seizure, Coma
How is Hypoglycemic Shock treated?
D50 + D5 Infusion
What happens to the brain if the sugar is low?
Brain will use up all the sugar, then fats/ketones, eventually leading to brain death and apoptosis
