Patho: DM day notes

Stuff about why we care about DM:

• 35-45% of hosp pts are DM. sometimes they are under the care of an ortho doc who doesn’t know their shit on DM. unfortunately Dr. Ortho writes the MAR instead of using the Rx’es from the pt’s home. Sometimes you have a smart hospitalist or dietitican to manage their insulin orders.
• DM rates jumped 30% in the last some odd years.
• People die daily from DM, either their mismanagement or our mismanagement. Type 2 is truly manageable. DM pts are doing their best managing their DM—don’t mislabel them as noncompliant.
• How does insulin work normally? [AP review]: BS of 70-110. Insulin comes out of my pancreas when there’s lots of glucose in my blood after meals or after glucagon [which lets out stored sugar from my liver.] My blood sugar should always be between 70 and 110, whether I just ate or not!
• What happens when I’ve got the flu [w/o DM] and I’m not eating, and I run out of sugar stores b/c I don’t want to eat? You break down fats next, and you build up ketones, which makes your breath smell like juicy fruit.
• If you have a Diabetic’s diseased kidney, and you put it in a relatively healthy person, it will heal the tissue.
• “I have never seen anything other than U100 insulin.”

Case: Mr. Bertucchi age 50, has just been transferred from the ED to MS. Hi FSBS [fingerstick bloodsugar] is 388 and the ED nurse reports insulin was given. His VS were 37.7-88-22 148/78. He is A & O times one. Skin warm and dry, says he needs some water [polydypsia] and is squirming around in bed. His daughter is at his bedside.

He has the following orders:

Sliding Scale insulin with Lispro ac and hs

Rocephin 1 Gm every 24 hours IVPF

Dressing change to foot BID

Culture to open wound ASAP

What’s missing: When was insulin given, what was the FSBS before that, how much insulin was given. Admitting Dx. What’s his K+ level? [normal would be= 3.5-5] Where’s his wound, and why did I have to look in the orders to find it? Why is he squirming? How old is this daughter and is it appropriate she’s here? What’s his normal mentation if he’s AOx1. How long has he had DM? How is his DM managed at home?

What’s his I/O, what kind of fluids is he on? [let’s hope it’s NS]

What’s up with him? HHS: Hyperosmotic Hyperglycemic State [non-ketotic]. Hyperglycemic meaning: too much glucose and no insulin, and no fat breakdown. The glucose is in the blood causing hyperosmotic [high solute; chunky] blood, which draws in fluid from tissue. So your body is dumping as much fluid into the veins as possible, and the sugar ain’t going no where. The kidney then recognizes too much fluid in the body, so that kidney secretes Aldosterone to diurese the body. Hence, polyuria, polydipsia, and polyphagia. The reason his LOC is down: b/c he has all this sugar but his brain is starving for sugar.

He doesn’t need insulin at home—he uses oral meds. [wait, how do I know that?] Type 1 DM means your beta cells are fried—you’ll never get insulin out of them—but this man does get some insulin.

How did he spike this sugar? The infection spiked his sugar over the edge. How: The body wants lots of food/fuel to fight the infection—the liver is spitting out glucose like nuts to fight the infection. The metabolic needs of the inflammatory response require all that sugar—but the body cannot produce quite enough insulin to manage a body thru that infection process. His oral meds also cannot deal with this much glucose overwhelm.

Moral of the story: type 2 non-insulin dependent DM pt got a bug, spiked his sugar levels and got HHS.

How bad is a BS of 388? 388 is that bad—‘175’ is “ok” for a diabetic. Don’t let pts or RN’s tell you that “300 is their normal”—that’s not ok. BS at that level over time causes all the nasty DM toe-cutting-off-stuff.

IV insulin: if it’s in an IV it had better be “regular”, and if anyone is on IV insulin, get them to the ICU. They need FSBS Q 1 hr, and that’s ICU type care.

Lispro: is appropriate for him. It’s fast acting. Like humalog.

Fast acting: Lispro, Humalog

Short Acting: Regular

Moderate: NPH

Long: Lantus

Things to know when giving insulin:

1. onset
2. peak
3. duration
4. Make a light sine wave in pts FSBS; keep their BS’s steady. DO NOT let a pt’s FSBS bounce from too low to too high: it causes major complications.
5. If giving fast acting insulin, make sure the tray is in their hands; too many things happen with trays.
6. If the tray isn’t there, get them graham crackers and milk instead of orange juice. Otherwise you spike their sugar. Deb doesn’t like the OJ, even when it’s ordered for low BS
7. Never mix with lantus. Other stuff can be mixed. It’s a good idea because you can moderate their effects over time and keep FSBS steady.
8. Sliding scales: MD’s like the “noah’s ark” routine w/ sliding scales: always multiples of 2. MD’s pick their ‘favorite flavor’ of sliding scale, instead of customizing it to the pt. You can always take a few extra FSBS to track their responses. Call the doc with a request for a better scale—make your proposal.
9. If the pt’s FSBS is off the scale: there is no order for what’s outside the range—you have to call the doc. If someone’s ass is out past 400, try to get that insulin in them via their MD order or the local hospitalist or whoever w/in 30 mins.
10. Don’t hold food: the secret w/ most health issues is consistency: same meals, same times, etc.
11. Post-prandial BS: after the insulin; only some doctors order this. They are a clever way to track body response to insulin, and whether or not the insulin orders are suitable.
12. Rescue remedies for low BS: glucose gel subling, D50 IV, injection of glucagon [like seizing], orange juice is often the order but Deb doesn’t like that much.
13. Why do HHS and DKA pts drop in K+. These crises, the K+ goes to where: it is diluted in the excess fluid volume, and it is peed out with the hyperosmolar state of the blood. Life threatening arrhythmias like V Tach can show up.

Case: Amy age16, has just been admitted to your unit for a full work-up. She has recently experienced weight loss, fatigue, poor grades and complains of constant hunger. Her symptoms began suddenly. Her FBS was 425 and her urine was positive for ketones. She has no family history of DM. Her mother is at her bedside.

What’s happening: She is Type 1 sudden onset, in ketoacidosis.

What else might you see: juicy fruit breath, low potassium [K+], low bicarbonate, high CO2; kussmal breathing to blow off CO2.

First step: get that blood sugar down; she has no insulin of her own.

How did she get it: either virus, auto immune, trauma, “idiopathic” [we dunno.]

When does onset occur: Deb has seen it as early as 8mo, usually before 30.

What does onset look like before it gets ugly; tiredness, etc.

How do we want to get her FSBS down; IV drip regular and put her in ICU. On drip insulin, there should be a finger stick Q 1 hr, insulin will be adjusted accordingly.

Tell mommy about DM, tell her about DM…when she’s stable. Under 20 yrs old, DM is forgiving; and she will not have complications yet.

Give her fluids for dehydration; NS: a bolus; like 2000 cc’s wide open.

Once her BS is down, start DM education—leave them alone until they are out of crisis.

Let’s imagine our girl is now at 40 FSBS: first step is: stop insulin. Now! Bolus of D50. Document, call the MD. LOC: probably not too good. Assess skin; might be diaphoretic. She might be in seizure: insulin shock/hypoglycemic shock—there’s no FSBS at which people start seizing: everyone’s brain conks out at different points. Seizure happens b/c the brain is starving. The low hurts more than the 400+ high! People can feel just dandy at 400 FSBS.

She is a candidate for insulin pump: why? She is Type 1, she is clever enough to use it and understand her diabetes. They are filled w/ lispro usually, they work like a PCA: a basal drip rate and an on demand button. Stays in place for about a week.

Just because you’re Type 1 DM doesn’t mean that you can’t eat sugar any more; you just have to increase the insulin and be vigilant.

Your type 2 DM pts need to be more cautious w/ food b/c: they have desensitized cells and their oral meds ain’t that hot.

• Why Weight loss? Diabetes affects the way your body uses blood sugar. Even when you eat as much as usual, you may lose weight if your muscle tissues don't get enough glucose to generate growth and energy. This is especially true with type 1 diabetes, in which very little sugar gets into your cells. With uncontrolled diabetes, sugar lost in the urine may also contribute to weight loss.
• Labs: The A1c test evaluates the average amount of glucose in the blood over the last 2 to 3 months. It does this by measuring the concentration of glycosylated hemoglobin. As glucose circulates in the blood, some of it spontaneously binds to hemoglobin A (the primary form of hemoglobin in adults). Hemoglobin is a red protein that carries oxygen in the red blood cells (RBCs)). Once the glucose is bound to the hemoglobin A, it remains there for the life of the red blood cell (about 120 days). The more glucose that is in the blood, the more that binds to hemoglobin A. This combination of glucose and hemoglobin A is called A1c (or hemoglobin A1c or glycohemoglobin). A1c levels do not change quickly but will shift as older RBCs die and younger ones take their place.

John Faust, age 57, is one day post THA [replacement]. John has been a Type II diabetic for 5 years well controlled with meds and diet. Last night and this morning his FSBS has been 330 and 278 respectively. John is very upset when you arrive with his insulin.

• Why is he pissed? B/c he doesn’t take insulin at home…and if you’re given insulin it means you’re getting sicker. Why does he need the insulin? B/c of the stress of surg and stress of pain, etc.
• What screwed up his blood sugars so much? The surgery, which puts stresson the body. Why does stress whack you out? Bc glucocorticoids are released during stress: they are ‘gluco’ therefore they jack up the FSBS.
• He says, “ok, I won’t eat.” This will not help him b/c he needs the food to help his healing, and the glucocorticoids are still being made. He needs the insulin and the food.
• What do we tell him? We need to give you insulin temporarily to get you thru this stress phase, your body is still producing glucocorticoids and we need to keep up with them.

Complications:

DM is top cause of Renal Failure

QOF is decreased with moderate compliance

Complications can still show up with high compliance and tightly reigned FSBS.

CAD, atherosclerosis, HTN, neuropathy, blindness, amputations. Amputation and blindness