- Diabetes Mellitus
800,000 new cases in US each year
Leading cause of non traumatic amputations, end stage renal disease and blindness among adults.
3rd leading cause of death by disease mostly due to cardiovascular complications
The primary goal is controlling glucose and preventing complications.
Physiology and Pathophysiology
Insulin is an anabolic…storage hormone. It moves glucose from the blood into the muscles, liver, and fat cells. Once inside those little cells the insulin will…transport and metabolize glucose for energy, stimulate the storage of glucose in the liver and muscle…yes in the form of glycogen. Tells the liver to stop the release of glucose. Helps the storage of dietary fat in adipose tissue. Speeds up the transport of amino acids from dietary protein into the cells. It also stops the breakdown of stored glucose, protein and fat.
Glucagon is secreted by the alpha cells in the islets of Langerhans and this is released when the blood glucose is to low, and it stimulates the liver to release some of that stored up glucose.
Insulin + Glucagon so happy together to maintain a constant level of glucose in the blood.
How does the liver produce glucose? At first it does this by the breakdown of glycogen=glycogenolysis. Then after 8-12 hours without food …breakdown of non carbohydrate substances…including amino acids=gluconeogenesis.
- Type One--Destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. And with this impaired function of above stated role of insulin.
- Type Two--Impaired insulin secretion and insulin resistance. Not only is there a problem with making insulin the tissues have a decreased sensitivity to it.
- What is the Dawn Phenomenon?
It is a normal blood sugar till about 3am with a gradual rise in the early morning hours. This is a common problem. The treatment= patient controlled by changing the time and dose of insulin-NPH-by 1-2 units.
- What is the Somogii Phenomenon?
It is hypoglycemia at night with hyperglycemia in the morning. Caused by to much insulin or an increase in sensitivity to insulin. The treatment = a gradual lowering of the insulin dose and increase in diet at the time of the hypoglycemic reaction.
Risk Factors we should already have beaten into our brains.
- The 3 Clinical Manifestations--ppp
- Other Signs/Symptoms
Weight loss, fatigue, weakness, tingling or numbness in the hands or feet, dry skin, slow healing sores, recurrent infections
- Diagnosing DM--Of course high blood glucose levels…Fasting plasma glucose levels of 115mg/dL on more than one test.
Management--Diet, weight control, exercise. The ADA recommends 50% from CHO, 30% from fats, 10-20% from proteins. Recommend high complex carbs, high soluble fiber foods, few simple sugars, limit fats.
- To lower the glycemic response--combine starch foods w/ protein and fat to slow the absorption of the starch. Eat raw foods, and eat whole fruit. The goal is to slow down the response.
- Remember to educate about the effects of ETOH and oral anti- diabetic meds. Side effects may include--facial flushing, warmth, headache, nausea, vomiting, sweating, thirst.
- Why walk? It increases the uptake of glucose by muscles and improves the utilization of insulin.
- Insulin Therapy
Short acting--Regular. Onset= ½ to 1 hour. Peak=2-3 hours. Duration=4-6 hours. Given 20-30 minutes before meal.
Intermediate--NPH, Lente. Onset=3-4 hours. Peak=4-12 hours. Duration=16-20 hours.
Long acting--Lantus. Peakless. Slow sustained action. Onset= 6-8 hours. Peak= 12-16 hours. Duration=20-30 hours. Used to control fasting glucose levels.
Absorbed faster when injected into the abdomen. Do not inject in a limb that will be exercised. (increases speed of absorption)
Insulin pumps are the most effective at maintaining blood glucose levels.
- Oral Antidiabetics
Cannot be used during pregnancy. Sulfanylurias--stimulate the pancreas to secret insulin and improves action at the cellular level. Should not be combined w/ ETOH. Biguanides--glucophage.(metformin). Can only be used w/ presence of insulin. Watch for drug interaction:Corticosteroids, diuretics, anti-coagulants, oral contraceptives.
Blood sugar level less than 50-60. Mild--sympathetic nervous system stimulated; A surge of adrenalin, causing sweating, tremor, tachycardia, palpitations, hunger, nervous. Moderate--brain cells deprived of food, impaired function of the CNS, can not concentrate, headache, light head, confusion, numb lips and tongue, slurred speech, emotional/irritable, double vision, drowsy. Severe---CNS change so impaired they need help. Disorientated, seizures, may not arouse.
To prevent---Feed the Peak. Know insulin/med peak times, and give food at that time.
Treatment--2-4 glucose tabs, 4-6oz fruit juice, 6-10 life savers, 2-3tsp of honey, love the frosting!
Caused by no insulin, illness, infection, and undiagnosed DM. This leads to a disorder in metabolism of CHO, protein, fat. 3 HUGE problems: Dehydration, electrolyte loss, acidosis.
- Here it is….There is not enough insulin…decreased amount of glucose are getting to the cells…which makes the liver make lots of glucose. Resulting in hyperglycemia. The kidneys try and try to secrete the extra glucose…and there goes the water and the Na+ and K+….
Lots of urination leads to dehydration and extreme lyte loss. Because of the decreased insulin Fats breakdown into fatty acids and glycerol.
Then the liver converts the free fatty acids into Ketone bodies which are acids…and lead to metabolic acidosis.
The blood glucose may be 300-800 or 1000 or more!
- Ketoacidosis--will see….
Low serum bicarb --0-15
Low PCo2--10-30 reflecting respiratory COMPENSATION for Metabolic acidosis.
Depending on the water loss Na+ and K+ may be high low or normal.
With dehydration will see---High creatinine, high BUN, high Hgb, high Hct.
Treatment As Ordered may be….
Dehydration--may need 6-10liters normal saline solution. 1liter/hour for 2-3 hours then switched to ½ NS.
Lyte loss--initially loss of K+ with dehydration. May need 40mEq/hour for several hours.
Acidosis--insulin IV at slow rate of 5units/hour. Hourly blood glucose checks.
- Insulin Drip Math
Convert hourly rates of insulin infusion to IV gtt rates.
Example= 100 unit of R insulin mixed in 500cc of 0.9NS.
Order= 5 units/hour
Math= 5 units x 5cc= 25cc/hour
Infuse separate. When mixing insulin drip, flush solution through the entire set and waste the first 50cc. Why is that?? Insulin molecules adhere to the glass and plastic infusion sets so the initial fluid has a decreased amount of insulin.
Always run the insulin continuously or the Ketone bodies will return.
Complications to come another day!