Diabetes Mellitus

Treatment

Insulin Regimen

Sliding Scale

Continuous subcutaneous insuline infusion (CSII)
w/ meal bolus, BS before meals, carbohydrate counting

Compliications

acute

chronic

hypoglycemia

hyperglycemic hyperosmolar nonketotic syndrome

diabetic ketoacidosis/diabetic coma

macrovascular disease: CAD, CVD, PVD

Microvascular disease: kidneys & eyes

neuropathic disease: involving nerves

risk factors: >50% noctural, too much insulin or oral medication (relative to available glucose), not compensating: weight loss, menses, exercise, EtOH, decreased caloric intake

--> epinephrine and glucagon release

can also occur w/ sudden BG drop, though hyperglycemic (e.g. 14 to 8mmol0

treatment

mild-moderate: 15-20g of simple (fast-acting) carbohydrate:
3-4 glucose tablets
175 mL fruit juice/regular soft drink
6 Life saver candies
Nothing with fat!!
check BG in 15 mins
Snack: 1 protein, 1 starch
Recheck BG

Severe: 1mg glucagon (or D50W)
-pt wakes up-> oral starch snack
check BG in 15 min--OK--> Recheck BG in 2-3 hrs

mostly caused by underlying or concomitant infection (40%) - i.e. UTI, missed insulin (25%)

signs and symptoms

fruity breath

Kussmaul respiration - deep, brief, fast (to get rid of CO2 due to low pH in acidosis)

glucose in urine

diuresis, dehydration, electrolyte imbalance

leads to metabolic acidosis

GI symptoms

low blood sugar so fats used as energy source (fat --> glycerol --> glycogen --> glucose --> hyperglycemia), but produce KETONES as a by-product --> metabolic acidosis

Treatment

A: patent airway, intubate if obtunded

B: oxygen, as per MD order

C: IV NS until BP stable and urine output 30-60mL/hr
When BG approaches 12-14 mmol/L, switch to D5W. Avoid hypoglycemia
Fluid volume expanded? - correct fluid loss w/ 1/2 NS plus K+ (b/c decreases w/ insulin admin)

NPO

Insulin infusion: standard order - 0.1 units/kg/hr

Continue regimen for 36-48 hours

BG decrease rate: aim for <5 mmol/L/hr

WATCH OUT FOR CEREBRAL EDEMA R/T DKA

Neurological deterioration: headache, irritability, decreased LOA, decreased HR

assoc'd w/ bicarb administration, too rapid fluid and insulin treatment

T2D

BS >34 mmol/L

NO KETOACIDOSIS

Treatment: same as DKA + more IV NS