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DKA, HHNK and Inpatient Glycemic Control

DKA, HHNK and Inpatient Glycemic Control . Our Most Extreme Home Fitness Program. DM60 X. Normal Glucose Homeostasis: Fasting State. insulin -. glucagon +. 100. Insulin +.

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DKA, HHNK and Inpatient Glycemic Control

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  1. DKA, HHNK and Inpatient Glycemic Control

  2. Our Most Extreme Home Fitness Program

  3. DM60X

  4. Normal Glucose Homeostasis:Fasting State insulin - glucagon + 100 Insulin + Adapted from Kahn SE, Porte D, Jr., In: Porte D, Jr., Sherwin RS, eds. Ellenberg & Rifkin’s Diabetes Mellitus, 5th ed. 1997:487-512.

  5. Glucose Homeostasis: Fed State 140 insulin - glucagon + Insulin + Adapted from Kahn SE, Porte D, Jr. In Porte D, Jr, Sherwin RS, eds. Ellenberg & Rifkin’s Diabetes Mellitus, 5th ed. 1997:487-512.

  6. Type 1 diabetes Result of insulinopenia Most cases are immune mediated INSULIN DEPENDENT In the absence of sufficient insulin, patients are prone to ketosis 10% of DM patients May occur in adulthood

  7. Natural History of Type 2 Diabetes 350 300 250 200 150 100 50 Glucose (mg/dL) 250 200 150 100 50 0 Insulin resistance Relative function (%) Insulin level -Cell failure -10 -5 0 5 10 15 20 25 30 Years of diabetes Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

  8. DKA vs. HNNKCutoff between DKA and HNNK is somewhat arbitrary

  9. Pathophys: Absolute or Relative Insulin Deficiency Absolute: newly presenting, young patient with type 1DM Relative: circulating insulin is present, but excessive counterregulatory hormones Catecholamines, glucagon, cortisol, GH Fast Slow

  10. How Can a Patient with Type 2 Diabetes Present with DKA?

  11. LABORATORY CRITERIA OF DKA AND HHNK DKA Laboratory Criteria Glucose, mg/dL >250 >600 Arterial pH <7.3 >7.3 HCO3, mEq/L <15 >20 BUN, mg/dL <25 >30 Osmalality >330 <320 Ketones*  ++++ -/+    Urine >+3 - or small    Serum + at >1:2 dilution - or small HHNK

  12. Case Discussions

  13. Warm-up Questions The patient is NPO after midnight. How do you adjust the…. HS Lantus? AM Lantus? Morning 70/30 dose

  14. Action Profiles of Insulin Analogues 2 3 4 5 6 7 8 9 12 13 14 15 16 17 18 19 20 21 22 23 24 0 1 10 11 Aspart, Lispro, Glulisine Regular NPH , Detemir Glargine Plasma insulin levels Hours

  15. 73 y/o man admitted with CHF. His metformin and pioglitazone are d/c’d. You start insulin. His admission glucose is 154 mg/dl. He has improved glucose levels with his current insulin regimen. He is ready for d/c You decide to prescribe___________.

  16. A Common Clinical Scenario • The nurse calls at 9pm. The patient’s glucose is 68 mg/dl. The patient was given apple juice and crackers. The patient is on glargine and glipizide. The nurse is uncomfortable giving the glargine. You recommend….. • Would it make a difference if the patient has type 1 DM?

  17. Patient admitted for pneummonia Her A1c 1 month ago was 9.2% on 70/30, 30 units qbreakfast and 20 units at dinner. Intermittent hypoglycemia when she misses lunch. You decide to start a multi-dose regimen.

  18. 19 y/o patient with Type 1 DM Admitted for a head injury after a bicycle accident. Last A1c was 6.3%. The trauma surgeon calls to inform you the patient can be seen in the AM. Pt controls her DM with an insulin pump. How will you assess her insulin needs?

  19. 3 ?s to Ask for an Insulin Pump What is (are) the basal rate? What is the carb counting ratio? What is the sensitivity index?

  20. Woman w/ Type 2 DM Admitted for an asthma exacerbation DM treated with metformin and glipizide Tolerating POs Random glucose is 224mg/dl. Creatinine of 1.6mg/dl Solumedrol IV q 6 hours.

  21. BASAL

  22. BOLUS

  23. BASAL

  24. BOLUS

  25. BASAL

  26. SLIDING SCALE

  27. Starting Insulin TDD: 0.4 units/kg for BG 140-200 mg/dl TDD: 0.5 units/kg for BG 201-400 mg/dl ½ TDD as Glargine ½ TTD as Lispro before meals Reduce Glargine by 20% before meals Use supplemental lispro (SSI) and ADJUST INSULIN DOSES.

  28. Day 2 Fever to 102 degrees. BP 95/42 mmHg, HR 115. Decreased mental status and worsening respiratory status. Pt Tx to ICU and intubated Her glucose levels over past 24 hours have ranged from 228-324 mg/dl despite increasing insulin doses.

  29. Days 4 and 5 On day four Glucerna TF are initiated at 10 cc/hr and titrated by 10cc each hour until at a goal rate of 80cc/hr. The patient has been transferred off the insulin drip with 80 units of glargine daily. The following day the patient is NPO for a bronchoscopy. The TF are held at MN.

  30. By day 7 of the hospital course the patient is eating 50% of her meals.

  31. Another Case Patient presents with new onset DM / HHNK. After 24 hours on the insulin drip the patients glucose levels are at 130 mg/dl. How do you transition off the insulin drip.

  32. 63 y/o with AMI DM is well controlled on metformin and glipizide – last A1c 6.2%. Cath reveals multi-vessel disease. CABG is recommended. Post-operatively the patient is placed on an insulin drip. 48 hours post-op the pt is Tx to MDI. As the time of D/C she wants to know if she can go back on pills for her diabetes.

  33. Diabetic Ketoacidosis

  34. 19 y/o male is brought to ED via ambulance Found unresponsive on his sofa History of diabetes EMT reports Copious quantities of black colored vomit were evident. Paramedics concerned about social situation No family is available

  35. Physical exam BP 101/72; HR 123; Resp 32; T 34.8 °C; Pulse Ox: 100% on room air. General: 65 Kg, thin male who responds to simple ?s w/ moans OP: very dry mucous membranes and a moderate amount of dried, black material which is strongly Gastrocult positive. Respiratory pattern is rapid and deep breaths (Name?)

  36. Initial Course NSS at 200cc/hr is begun Serum glucose determination (Accucheck) was HI A sample of the blood was sent to the lab for a definitive serum glucose level.

  37. How does this affect your differential diagnosis? What additional care would younow render this patient?

  38. The next phase in treatment • Regular insulin 10 units IV while waiting for the lab results • The results came back shortly • ABG pH of 6.92, CO2 of 9 and a bicarb of 2. The WBC count was 62.6 • H/H 14.4 mg/dl / 43.5%.

  39. More labs Na+127, K+5.2, Cl- 87, CO2 < 5, BUN of 32, Cr 1.5, Blood glucose 1,582. Serum ketones were positive at a dilution of 1:32.

  40. 1. How do you interpret these results? 2. What additional treatment would you add?

  41. Key Points Lack of insulin or insulin utilization sets up a chain of events leading to DKA. A metabolic cascade results in profound dehydration, cellular starvation and acidosis. A search for precipitating cause is always indicated

  42. Key points (cont’d) Total body K+depletion is almost always present. Observe closely and replete if K+ <5.0 (pending renal insufficiency) Large fluid deficits (5-10 L), should be replaced aggressively, Continue treatment until acidosis is corrected

  43. PRECIPITATING FACTORS Diabetes: New onset, Poorly controlled, Non-adherence, CSII (pump) failure Acute illness: Infection, MI, Pancreatitis, Abdominal catastrophe, CVA, Severe burns, Renal failure Medications: Glucocorticoids, Somatostatin, Hyperalimentation Substance abuse: Alcohol or Cocaine Idiopathic -20% of DKA

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