Fill in the blank:

Insulin ______ the uptake of ______ into the ____.

Insulin increases the uptake of glucose into the cell.

How does K+ enter the cell?

Under the influence of insulin

What is the cause of Diabetes Mellitus?

A decreased production or lack of insulin

90% of DM is insulin or non-insulin type?

Non insulin

Name several factors that increase blood sugar during times of stress.

increased levels of cortisol, glucagon, catecholamines, and growth hormone

(stress makes management more difficult to control)

Name 4 characteristics  of Type I diabetes.

-Juvenile onset (insulin dependent)

-they are prone to Ketoacidosis

-Assoc w/ autominnume disease

-often have systemic complications (nephropathy, retinopathy, neuropathy)

Name several characteristics of Type II diabetes.

- Maturity onset (non-insulin dependent)

- NOT prone to ketosis (because some insulin is produced)

-patients are often OVERWEIGHT

-not assoc w/ islet cell antibodies

-accelerated physiologic aging

if a patient w/ Type II DM is poorly controlled, what is the effect on the organ?

What about if the pt is Tightly controlled?

1.5 years for every chronological year of the disease

tightly controlled-1.2 years for every chronological year of the disease

What is the most frequent cause of death in older diabetics?

What is the percentage of pts w/ HTN?

CAD-MI

30-60% have associated HTN

Name three other cardiovascular pathologies.

Cardiomyopathy

Ventricular dysfunction

Cardiac autonomic neuropathy (degeneration of the heart's innervations)

*Type I has more organ pathology!*

What renal considerations should we think of in someone w/ DM?

Prone to renal failure

urosepsis

arteriosclerosis of the renal arteries 

arterioles-deabetic glomerulosclerosis

If someone w/ DM has GI pathology what flag should be raised for us?

Decreased gastric emptying!!

(may need to do a rapid sequence)

Name 2 concerns with retinopathy.

Microaneurysm

Hemorrhage

DM often have neuropathy, what system is primarily affected, and what are some s/s we should look for?

Peripheral nervous system

s/s: pain, weakness, absent tendon reflexes, paresthesia, pupilary changes, ocular palsy, myopathies

Name 5 causes of ketoacidosis:

1) Patient stops taking their insulin

2) Infection

3) MI

4) Pancreatitis

5) Pregnancy

Ketoacidosis etiology is from:

 an absolute or relative lack of insulin

-Hyperglycemia

-production of ketones from the metabolism of free fatty acids

Name the s/s of ketoacidosis:

-vomiting

-abd pain/tenderness

-SOB

-Hypotension

-Dehydration

-dry skin

-High urine output

Name three causes of fluid and electrolyte disturbances.

1) Vomiting = loss of K+

2) Hyperglycemic osmotic diuresis

3) Fluid shift from intracellular fluid to extracellular fluid (due to they hyperosmolarity of ketoacidosis)

**K+, fluid and insulin replacement are important**

In emergency anesthesia for ketoacidosis, how is insulin therapy started?

What happens when the glucose reaches 250 mg/dl?

With a 10 unit bolus, followed by an infusion.

-Add 5% dextrose to the IV

In emergency anesthesia for ketoacidosis, what three things do you monitor very carefully?

Glucose

Potassium

pH

In ketoacidosis, insulin binding sites are limited, so you should expect a decline of what?

75-100 mg/dl/hr regardless of rate

What is the typical volume deficit in ketoacidosis?

3-5 liters

What lab value falls as glucose decreases?

What do we do about it?

Sodium will fall

We should utilize normal saline 250-1000 cc/hr depending on volume depletion

Name two considerations for the diabetic patient the day of surgery.

-Make sure they have been NPO for greater than 8 hrs.

-Draw a blood sugar at 6 am & start D5LR (D5 1/3 for renal failure pts)

What should you administer for the Type I diabetic the day of surgery?

Humulin R based on blood sugar results or some will give half the usual morning insulin dose

blood sugar checks every 1 hour!

What are your considerations for Type II diabetics the day of surgery. What should be held?

-No oral hypoglycemic agents the day of surgery

-FBS between 120-200 is acceptable

-Treat w/ Humulin R carefully since the pt typically doesn't use insulin

-Blood sugar checks should be every 1-2 hrs intra-op in recovery & treated Humulin R

What is the goal of the tight control regimen?

When do we do a check & what do we start?

How is an insulin infusion given?

-Goal is b/t 80-200

-Do a 6 am blood sugar check & begin IV w/ D5W w/ 20 meq KCL at 50 cc/hr

-Begin an insulin infusion (50 units in 250 cc) on an infusion pump