CCRN

 Acute hypoglycemia

 Diabetes insipidus

 Diabetic ketoacidosis

 Hyperglycemia

 Hyperglycemic

hyperosmolar nonketotic

syndrome (HHNK)

 Syndrome of

inappropriate secretion

of antidiuretic hormone

(SIADH)

•  Recognize normal & abnormal physical assessment

  findings

•  Recognize signs and symptoms of endocrine

  emergencies, initiate interventions, & seek assistance

  as needed

•  Identify and monitor normal & abnormal diagnostic

  test results

•  Implement treatment modalities for acute

  hypo/hyperglycemia (e.g., insulin therapy)

•  Monitor patient and follow protocols for surgery

  related to the endocrine system

•  Manage patients receiving medications & monitor

  response

• Is bad!!! Avoid it!

• Associated with higher mortality!!!

• Serum glucose < 70 mg/dL

• Too much insulin in relation to glucose

• Identify cause; predisposing factors

• Frequent glucose monitoring

• Beta-blockers – check BG more frequently

Hypoglycemia

 Causes:

• Too much insulin

• N/V

• Interrupted feedings (oral, TF or parenteral)

• Strenuous exercise or stress

• Excessive ETOH

• Adrenal insufficiency

• Severe liver disease

• Pregnancy

 Usually when BG < 50 mg/dL

 CV (Initial symptoms)

 Palpitations

 Tachycardia

 Diaphoresis

 Pallor

 Cool skin

 Piloerection

 Irritability

 Neuro

 Blurred vision

 Slurred speech

Weakness

Headache

 Difficulty concentrating

 Confusion

 Fatigue

 Diplopia

 Anxiety

 Tremors

 Staggering gate

 BG 20 – 40 mg/dL

Seizures

 BG < 20 mg/dL

Coma

 If conscious

 10 – 15 g of Carbohydrates

 Glucose tablets or gel

 4 oz. juice

 If unconscious with IV access

 1/2 to 1 amp of Dextrose 50%

 Consider 5 - 10% Dextrose in water infusion

 If unconscious without IV access

 give glucagon 0.5 – 1 mg IM

 Provide longer acting carbohydrate once stabilized

 Tonicity of fluids

Isotonic

Hypotonic

Hypertonic

Colloids

 The measure of solute concentration, defined as

the number of osmoles of solute per liter of

solution (mOs/L)

 Normal 275 – 295 mOs/L

 Calculation:

(2 x Na+) + Glucose + BUN

18 2.8

OR, if glucose is normal: 2 (Na+)

Osmolality of IV fluids

Isotonic

Isotonic IV fluids

 Normal Saline (308)

 Lactated Ringers (273)

Hypertonic

 D5 0.2 NS (321)

 D5 ½ NS (406)

 D5LR (525)

 D10

 2%, 3%, 5%, 23.4% Saline

Hypotonic

 0.45 NS (154)

 D5W (252) – Isotonic

in the bag

 Drives glucose, water & potassium into cells

 With DKA & HHS – replace volume 1st!!!!

 Regular insulin (IV) onset of action: ~5-10 min

 Regular insulin (SQ) onset of action: 30 min

 Peak: 1 – 3 hours

 Effects last 6 – 8 hours

Insulin at a glance…

Insulin at a glance…

 DM: Metabolic syndrome with fasting BG > 126 mg/dL

or A1C ≥ 6.5%

 Defect in insulin secretion, action of insulin or both

4 Categories:

 Type 1: Beta cell destruction resulting in absolute insulin

deficiency

 Type 2: Insulin secretory defect; resistance resulting in

relative insulin deficiency

 “Other”: due to other causes; genetic, medication induced

 Gestational Diabetes: due to pregnancy

 Estimates the effectiveness of diabetes mellitus therapy

 Normal value 4 - 5% (non-diabetic)

 6 - 7%: average glucose range 100-150 mg/dL

 > 7%: indicative of poorly controlled glucose levels

 Limitations:

 African Americans have greater glycation the other

ethnicities

 Unknown if the same cut-off points should be used to

diagnose children

 Anemia

• Estimated 25% of the US population

• 40% incidence age > 60

• High risk for developing CV disease & DM

 Any 2 of the following:

• Elevated triglycerides > 150 mg/dL

• Low HDL < 40 in males, < 50 in female

• Elevated BP: SBP > 130 or DBP > 85

• Fasting blood glucose > 100 or diagnosed Type 2 DM

• Waistline > 40 inches men, > 35 inches women

Alpha cells produce

glucagon

Beta cells produce

Insulin

Delta cells produce

somatostatin

Type 1 DM: Beta cells not producing insulin

Type 2 DM: Insulin resistance resulting in relative insulin deficiency

Stress, infection,

medications,

diet

Lack of

insulin leaves

too much

circulating

glucose

Osmotic

diuresis 

profound

water loss

Leads to

glucosuria,

dehydration

& electrolyte

Imbalance

Metabolism:

Accelerated gluconeogenesis

Glycogenolysis

Decreased glucose utilization

Increased lipolysis

Decreased lipogenesis

Abundant free fatty acids are

converted to ketone bodies

 Type 1 DM

 Undiagnosed Type 1

DM (20% of cases)

 Illness/Infection

 Trauma

 Surgery

 Non-compliance

 Pancreatitis

 Pregnancy

 Cushing’s Syndrome

 Hyperthyroidism

 Drugs

•  Thiazide diuretics
• Glucocorticoids (ie.
• prednisone)
• Diazoxide (hyperstat)
• Phenytoin
• Sympathomimetics

 3 P’s:

Polyuria (early), oliguria –

(late)

Polydipsia

Polyphagia

 Neuro:

Headache

↓ Deep Tendon Reflexes

(DTRs)

Visual disturbances

Hypo/hyperthermia

Decreased LOC –

advancing to coma

 CV:

Tachycardia

Decreased CVP & PAOP

 Pulmonary:

Kussmaul’s breathing

Acetone/fruity odor to

breath

 GI:

Nausea, vomiting

Abdominal pain

Weight loss

 Hyperglycemic crisis (BG 300-800)

 Metabolic acidosis

↓ pH: > 7.0 self correct, < 7.0 – consider bicarb

Serum bicarb < 20 mEq/L

Anion gap >15*

 Elevated serum & urine ketones

 Electrolyte imbalance:

Increased K+ (acidosis causes K+ to shift out of cell)

decreased Na+/Ca++

Na++ Cl-

K+ HCO3-

>12 – Metabolic acidosis

M: Methanol

U: Uremia

D: DKA

P: Propylene glycol

I: Isoniazid

L: Lactic acidosis

E: Ethylene glycol

S: Salicylates

 Fluid Replacement

• 0.9% Saline or Lactated Ringers (isotonic)

• Add dextrose to IVF when BG reaches 250 mg/dL*** (D5.45)

• Then, 0.45% saline @ 250-500 mL/hr

 Correct total fluid deficit (~ 50 – 100 mL/kg deficit)

Depending on fluid deficit:

 Administer 1-3 L during the first hour

 Administer 1 L during the second hour

 Administer 1 L during the following 2 hours

 Administer 1 L every 4 hours, depending on the degree

of dehydration

Insulin (Regular)

 Assess BG every 1 - 2 hours until goal is reached

 Run infusion at 0.1 units/kg/hour

 Then, insulin infusion goal: decrease glucose SLOWLY!!!

 Do not drop BG by more than 50-100 mg/dL per hour

 Transition to subcutaneous

 2 hour overlap period – you don’t want the patient going

without insulin

DKA – Insulin infusion

Transition to SQ insulin – Overlap by 2 hours

Goal is to shut down ketone production!!!

Electrolyte management in DKA

 Potassium

•  Total body potassium depletion

•  Average deficit is 3 – 5 mEq/L

•  Serum is initially elevated ~ 22%, normal ~ 74%

•  Transcellular shifts with insulin

 Sodium

•  Dehydration is not reflected in Na+ levels

•  Glucose has a dilutional effect on Na+

•  For every 100 mg/dL ↑ in glucose, Na+ ↓ by 1.6 – 2.0 mEq/L

   

 Phosphate

•  Depletion is common

•  Do not replace unless PO4 < 1.0 mg/dL

•  Replacement has littleimpact on outcome in DKA

 Bicarb

•  Replacement is not recommended unless the pH < 7

•  No impact on outcomes

^{Acidosis in Hyperglycemia}

For every 0.1 ↓ in pH there is 0.6 ↑ in serum K+

 pH 7.3   K+ 4.6

 pH 7.2   K+ 5.2

 pH 7.1   K+ 5.8

 pH 7.0   K+ 6.4

 pH 6.9   K+ 7.0

 aka “HHNS”,

 aka “HHNK”,

 aka “non-ketotic hyperglycemia”

 Usually Type 2 DM, can develop in Type I as well

•  Precipitated by physiologic stress (i.e. trauma, infection, etc.)

•  Non-compliance

•  Look for a cause!!!

 Absence of ketones

• Have enough endogenous insulin to prevent ketosis

• Glucose is often > 600, can be >1000 mg/dL

• Polyuria – early sign, then oliguria

  • urine gets concentrated

  • Persistent loss of glucose in the urine

• Osmotic diuresis

  • Serum osmo > 330

• Profound hypovolemia***

• Altered mental status***

• Takes days to weeks to develop

 pH   Normal or mild acidosis

 Sodium     Elevated – Hypernatremia

 Potassium         Low – Hypokalemia

 Magnesium        Low – Hypomagnesemia

 Phosphate         Low – Hypophosphatemia

 Hct/Hgb    Elevated – d/t dehydration

 Urine in glucose      Lots!!!!

Volume replacement

0.9% NS – 1-2 L

Colloids if in shock

Dextrose 5% when glucose is 250-300 mg/dL

0.45% Saline (when euvolemic & osmo < 320)

 Insulin (Regular)

Normalize glucose gradually – will not require as much

insulin as DKA

Monitor serum glucose hourly

+/- Bolus followed by infusion

•  (mixed opinions about bolus)

DKA VS HSS

Glucose level   

300 – 800 vs 600 - 2000

Ketones present?

Yes vs No

Acid/base

Met acidosis VS NL/mild acidosis

Anion gap present?

Yes (>15) VS No

Osmo

Elevated Severely           vs     elevated

(295-330)       vs          (330 – 450)

Type of Diabetic

Type 1 vs Type 2

Mortality

1% vs 5 – 10%

 Purpose: Fluid balance

 Formed in the hypothalmus

 Released from the posterior pituitary

 Has vasopressor qualities

 Swimming In ADH too much ADH

 Water intoxication (kidneys hold onto water)

 Severe Dilutional Hyponatremia

•  Serum Na < 120 mEq/L

 Decreased serum osmo (< 280 mOsm/kg)

 Urine osmolality > 100 mOsm/kg H20

 Decreased UOP

 Infection

 Variety of carcinomas/tumors

 Recent surgery (stress)

Complications:

 Severe dilutional hyponatremia***

 Seizure activity

 Cerebral edema

 ***Safety!!!***

 Remedy the problem

 Fluid Restriction

 Hypertonic saline (3%) – temporary

 Assess for fluid overload

•  Diuretics

 Na correction: Do not exceed 0.5 mEq/L per hour

•  12 mEq/L per day

•  Not exceeding plasma Na of 130

 **Lack of ADH**

 Failure of ADH release from the posterior pituitary

 Water loss up to 20 L/day

 Common causes (neurogenic most common):

• TBI

• Anoxic encephalopathy

• Meningitis

• Brain death

• Dilantin

• Tumors

 Polyuria

• Dilute urine (water loss)

• Urine specific gravity < 1.005 (Dilute)

• Urine osmo < 200 mOsm/L (Dilute)

 Extreme polydipsia

 Serum osmo elevated (> 295 mmol/L)

 Serum Na > 145 mEq/L (d/t H20 loss)

 Low urine osmo (50 – 200)

 Low urine specific gravity (< 1.005)

DI Treatment

 Replace ADH: (IV, IM, SQ, intranasal)

 Desmopressin (DDAVP)

•  2 – 5 units SQ every 4 – 6 hrs

 Fluid replacement

 Replace the free water deficit

 Correct slowly over 2 – 3 days

•  limit risk of cerebral edema

DI vs. SIADH

Serum Omso      Increased Decreased

Serum Na  Increased Decreased

Urine Spec gravity       Decreased Increased

Urine osmo                   Decreased Increased

Urine Na    Increased Decreased

A patient with DKA will exhibit an increase or

decrease in all of the following?

 Glucose      Increase

 Anion Gap Increase

 pH    Decrease

 Serum osmo         Increase

 Serum ketones      Increase

 Urine ketones        Increase

 Bicarb          Decrease