Class 3: Diabetes and DKA

What is diabetes?

a multisystem disease related to abnormal insulin production, impaired insulin utilization, or both.

Type 1 diabetes

• No insulin

• Autoimmune process

Type 2 diabetes

• Progressive decline in insulin production

• Insufficient insulin for body’s needs

Types of insulin

• Rapid acting

• Short acting

• Intermediate acting

• Long acting

Rapid acting insulins

• Novorapid and Fiasp (insulin aspart)

• Humalog (insulin lispro)

• Apidra (insulin glulisine)

Rapid acting insulins onset

Acts within 10-15 minutes; Fiasp can be 5.

Short acting insulins

• Humulin R

• Novolin GE Toronto

Short acting insulins onset

Acts within 30 minutes

Intermediate Acting insulin

• Neutral Protamine Hagedorn (NPH)

  • Humulin N

  • Novolin N

Long acting insulin

• Levemir (insulin determir)

• Lantus and Toujeo (insulin glargine)

• Tresiba (insulin degludec)

What insulin is long acting but could be intermediate depending on dose?

Levemir (insulin determir)

Continuous Subcutaneous Insulin Infusion (CSII)

• Small catheter under the skin

• Device infuses insulin continuously throughout the day (basal insulin) and then individual sets pump to deliver bolus with meals and other events

Types of Continuous Subcutaneous Insulin Infusion (CSII) pumps

• Tubed and tubeless pumps (Medtronic, Tandem T-slim, and Omnipod)

Type 2 Diabetes Management

• Diet

• Medications

• Exercise

Medications for Type 2 Diabetes

• Sulfonylureas

• Biguanides

• Thiazolidinediones (TZDs)

• Glucagon-like Peptide 1 (GLP-1) Agonists

• Sodium-glucose Co-Transporter 2 (SGLT2) Inhibitors

• Dipeptidyl peptidase-4 (DPP-4) Inhibitors

Sulfonylureas

• Glyburide

• Help your pancreas increase its insulin secretion

Biguanides

• Metformin (Glucophage)

• By itself does not cause hypoglycemia works predominantly on the liver.

• But if pt is going to a CAT scan being injected with dye, you have to hold metformin due to kidney damage risk

Thiazolidinediones (TZDs)

• Avandia

• Actos

• Decrease insulin resistance

Glucagon-like Peptide 1 (GLP-1) Agonists

• Victoza (liraglutide)

• Byetta (exenatide)

• Ozempic (subcut.) and Rybelsus (oral) (semaglutide)

• Increases insulin in response to food. Helps with feelings of fullness

Sodium-glucose Co-Transporter 2 (SGLT2) Inhibitors

• Inkovana (canglifloxin)

• Jardiance (emplaglifloxin)

• Forxiga (dapaglifloxin)

• Helps your body get rid of excess glucose in the urine. Your pt has to have good kidney function; anyone with renal impairment should not have this

• Could be taken by type 1

Dipeptidyl peptidase-4 (DPP-4) Inhibitors

• Januvia (sitagliptin)

• Helps the pancreas increase insulin production

Nutrition

• Healthy eating is more than the foods you eat!

• Encourage patients to eat well with Canada’s Food Guide to meet their nutritional needs

• ‘Diabetic Diets’ in hospital

Acute complications of diabetes

• Hypoglycemia

• Hyperglycemia (can lead to DKA in Type 1 and HHNKS in Type 2)

• Any other physical complications?

• Psychological complications?

Chronic complications of diabetes

• Cardiovascular disease

• Risk of infection

• Retinopathy

• Nephropathy

• Neuropathy

Diabetic Ketoacidosis (DKA)

• an acute metabolic complication of DM occurring when fats are metabolized in the absence of insulin.

• Caused by a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration

Does DKA occur in type 1 or type 2?

It is most likely to occur in type 1

DKA signs and symptoms

• Polyuria

• Ketonuria

• Hypovolemia (low BP, high heart rate)

• Dehydration

• Polydipsia

• Nausea & vomiting

• Kussmaul's respirations

• Fruity breath

Anticipate lab values

• Hyperglycemia

• Related to acidosis

• High H, acid

• Decreased pH

• Low Na

• High K

• Ketones

• Urinalysis: BUN will be slightly elevated

DKA Treatment

• IV fluids

• Infusion

• Possibly potassium

IV fluids for DKA

• initial fluid therapy regimen comprises an infusion of 0.45% or 0.9% NaCl IV solution at a rate to restore urine output and to raise blood pressure

• Want isotonic (NaCl) or hypertonic (R/L) fluids so it will stay in the vessels.

• 0.9% for volume

• 0.45% for dehydration

Insulin Infusion for DKA

• Usually regular insulin, but also can be insulin aspart (Novorapid), lispro (Humalog), and glulisine (Apidra)

  • Can't have long acting bc it doesn't work as fast

• Usually mix 100 units in 100 mL of 0.9% NS or can be 2:1 ratio

• When doing insulin infusion, it's a tandem setup; insulin is at the same height as the fluids

• Titration: Changes based on blood sugar

Why is potassium sometimes given for DKA?

Although initial serum potassium may be normal or high, levels can rapidly decrease once therapy starts because insulin drives potassium into the cells, leading to life- threatening hypokalemi

Monitoring during DKA

• Vital signs

• Glucometer

• Insulin infusion

• Cardiac: EKG

Expected vitals during DKA

• BP: decreased due to hypovolemia

• RR: increased due to kussmals resperations

• HR: elevated to compensate for low BP

• O2: may be normal or slightly decreased

Why may you have to switch to dextrose during insulin infusion for DKA?

Blood sugar can drop so fast; don't want risk of encephalopathy.

Why assess cardiac with an EKG during DKA treatment?

• Changes in potassium could lead to arrythmias

• Hyper and hypokalemia have characteristic changes that are observable on ekg tracings

How can DKA be prevented?

• Monitor blood glucose

• Proper insulin use, make sure it is not spoiled

• Follow recommendations