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Pancreas/Insulin/Glucagon/DM
NUR 878 Exam III
74
Physiology
Graduate
07/17/2014

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Cards

Term

Pancreas plays a key role in...?

a. digestion

b. metabolism

c.utilization of energy substrates

d. storage of energy substrate

Definition
All of the above
Term
True or False:  The pancreas has BOTH exocrine and endocrine capacities?
Definition
True
Term
Where is the pancreas located?
Definition
Retroperitoneal space near the duodedum
Term
Most of the mass of the pancreas is made up of exocrine cells.  These cells release (alkaline/acidic) digestive fluid into the pancreatic duct and released into the duodenum? (choose one)
Definition
Alkaline (to balance out GI acid so enzymatic rxns can take place)
Term
List the common hormones secreted by the pancreas
Definition
Insulin, glucagon, somatostatin, pancreatic polypeptide and amylin
Term
What ducts form the common bile duct?
Definition

Pancreatic duct

Hepatic duct

Cystic duct

(Discuss later:  gallbladder, liver and common bile duct procedures)

Term
What are the two types of tissues in the pancreas?
Definition
Acini cells & Islets of Langerhans
Term
Cells that secrete digestive juices into the duodenum
Definition
Acini cells
Term
Cells that secrete insulin and glucagon into the blood
Definition
Islets of Langerhans
Term
The Islets of Langerhans (1-2 million) are organized around capillary beds (absorbed quicker into blood).  Name the (4) types of islet cells.
Definition

1. Alpha cells secrete glucagon

2. Beta cells which account for the LARGEST number in the islets and secrete insulin

3. Delta cells secrete somatostatin

4. PP cells:  secrete Pancreatic Polypeptide_?what it does

Term
AKA-growth hormone inhibiting hormone
Definition

Somatostatin

(actually 6 forms in humans with unique receptors they attach to; secreted in the stomach, intestine, brain, delta cells of pancreas)

Term
Somatostatin is an (inhibitory/excitatory) substance?
Definition
INHIBITORY
Term
In the stomach-somatostatin...
Definition
SLOWS gastric emptying, the release of HCl acid and smooth muscle contraction.
Term
In the brain-somatostatin...
Definition
regulates or prevents the release of growth hormone by the hypothalamus
Term
In the pancreas-somatostatin...
Definition
SLOWS the release of insulin and glucagon
Term
Drug used to mimic somatostatin (brand name:  sandostatin).  Used to treat acromegaly (too much growth hormone), certain types of secreting tumors, and bleeding esophageal varices by producing POTENT splanchnic vasoconstriction.
Definition
Octreotide
Term
Normal glucose physiology incorporates the balance of food sources of glucose and the utilization of glucose.  Insulin and glucose are crucial in regulating...
Definition
Carbohydrate, fat and protein metabolism; There secretion is based on periods of feast and famine throughout the day
Term

What hormone plays a role in regulating GI function by restraining (or INHIBITING) the rate at which nutrients are digested and absorbed?

 

Definition
Somatostatin
Term
The blood sugar is maintained within a tight range of...?
Definition
90mg/dl in a 12 hour fast and 140mg/dl following a lg. meal
Term
The storage of glucose as glyocgen which occurs primarily in the LIVER and MUSCLE
Definition
Glucogenesis
Term
The storage of fat as triglycerides primarily in adipose tissue
Definition
Lipogensis
Term
Formation of glucose from lactate, pyruvate, amino acids and glycerol
Definition
Gluconeogenesis
Term
Breakdown of glycogen into glucose
Definition
Glycogenolysis
Term
Breakdown of triglycerides into free fatty acids and glycerol
Definition
Lipolysis
Term
True or False:  Insulin stimulates catabolism (breakdown) where lack of insulin causes anabolism (build-up) of carbs, fats, and amino acids for energy?
Definition
False; insulin stimulates anabolism and LACK of insulin causes catabolism
Term
The small protein comprised of 2 amino acid chains (alpha and beta) connected by disulfide linkages.
Definition
Insulin
Term
Once the proinsulin is cleaved by the Golgi apparatus for storage, insulin converts to it's (active/inactive) form?
Definition

Active; preproinsulin (insulin is translated by the ribosome)

and

proinsulin (endoplasmic reticulum has cleaved insulin)

are physiologically INACTIVE forms of insulin

Term
When released into the blood, insulin circulates unbound with a 1/2 life of...?
Definition
6 minutes
Term
Insulin is cleared...?
Definition
from the plasma between 10-15 minutes mostly by insulinase in the LIVER
Term
The adult pancreas secretes approximately how many units of insulin per day?
Definition
50 units/day
Term
List the cellular response to insulin
Definition
  • Cells increase their uptake of glucose (especially in muscle and adipose tissue)-when transported into BUT not used, muscle stores glucose as glycogen.  Glucose is also stored as glycogen in the liver (glycogenesis)-DOES NOT OCCUR in BRAIN and neuron tissue!
  • Cell membrane becomes more permeable to amino acids and potassium transport into the cell-
  • Insulin inhibits catabolism of proteins-FAVORS the formation of new proteins and muscle growth
  • INSUFFICIENT insulin causes lypolysis to occur where FAT becomes the primary source of energy-BREAKDOWN OF FATTY ACIDS produces acetoacetic acid (broken down into acetone and beta hydroxybutyric acid-FRUITY SMELL on breath during DKA) i.e. the KETONE bodies
  • Impacts ion transport pumps (Na/K/ATPase pump increases its activity causing K+ to be pumped INTO the cell)
  • Phosphorylation of many other enzyme reactions (metabolism)
Term
What controls insulin release?
Definition
  • Increase in plasma glucose
  • Increase in plasma amino acids
  • GI hormones (gastrin, secretin, cholesystokinin and gastric inhibitory peptide)
  • Other hormones (growth hormone, cortisol, estrogen, progesterone and glucagon)
  • Sympathetic BETA 2 AGONISTS (epinephrine increases plasma glucose by stimulating BETA 2 AGONIST receptors on the liver and adipose tissue when SNS is excited-Inc BS levels on Epi gtts)
Term
What is glucagon?
Definition
  • Secreted by alpha cells
  • OPPOSITE action of insulin
  • Works in concert with epinephrine, cortisol and growth hormone
  • Increases blood sugar concentration
  • Causes glycogenolysis (breakdown of glycogen in liver) freeing glucose, freeing fatty acids and inhibiting the storage of triglycerides
  • Increases blood flow through the kidneys
  • Inhibits gastric acid secretion

 

Term
Glycogen release is (inhibited/stimulated) by a rise in blood glucose?
Definition
Inhibited
Term
Glucagon is used for beta blocker overdose-why?
Definition

Positive inotropic effects

 

Term
Although controversial-used in GI lab to relax the sphincter of Oddi
Definition
Glucagon
Term
  • "Starvation in a sea of food"
  • BS Fasting>125mg/dl or random>200mg/dl
  • HbA1C-6.5% or greater (more exposure, more glucose attaches to hgb)
  • incidence on the rise (elderly, obesity and sedentary lifestyle)

 

Definition

Diabetes Mellitus-impaired carbohydrate, fat and protein metabolism due to lack of insulin secretion or insulin resistance

 

Term
Type I DM
Definition
  • Juvenile onset
  • Insulin dependent
  • Lack of insulin secretion
  • Viral or autoimmune-destroys beta cells of islet (can be familial)
  • Rapid onset-age 14 yo
  • S+S=fatigue, weight loss, polyuria, polydispia, intravascular dehydration, ketoacidosis (SEVERE insulin deficiency-SICK)
Term
Type II DM
Definition
  • 90% of all diabetic cases
  • Non-insulin dependent
  • Insulin resistance
  • Often occuring gradually after age 30 yo (but obesity can cause earlier diagnosis)
  • S+S=hyerinsulinemia, pancreas 'burns out', not enough insulin produced-transition from oral meds to insulin dependency
Term
What are the metabolic syndromes associated with Type II DM?
Definition
  • Obesity (belly fat)
  • Hyperglycemia
  • Lipid abnormalities (inc. triglyc, LDL, dec HDL)
  • HTN
Term
What else produces insulin resistance?
Definition
  • Polycystic ovarian syndrome
  • Glucocorticoids (Cushing's)
  • Steroid administration
  • Growth Hormone (Acromegaly)
Term
What happens in insulin deficiency?
Definition
  • Decrease glucose uptake into cells (high serum levels)
  • Spilling of glucose in urine (tmax occurs at 180-200mg/dl in the PCT-proximal convuluted renal tubule)
  • Glucosuria (hyperosmolar) produces water loss (polyuria) and dehydration and thrist (polydypsia)
  • Cells switch to fat (atherosclerotic and angiopathic changes) and protein metabolism (muscle wasting and fatigue) to survive; extreme hunger (polyphagia) in an attempt to replace amino acids
Term
Many proteins become glucose laden (saturated with glucose) even hgb.  What lab equates to this?
Definition
Hbg A1C
Term
List long term complications of DM
Definition
  • Thrombotic lesions (arterial thrombotic lesions distributed through extremeties, kidneys, eyes, muscle, myocardium, and nervous system):  MICROVASCULAR vs. MACROVASCULAR
  • Heart disease (70% of diabetics have HTN; 2-4x greater risk for stroke)
  • Vascular complications (Diabetics 17x more likely to suffer gangrene-VERY common in OR)
  • Blindness (25x more likely in diabetics)
  • ESRD
  • Neuropathy (occurs in 50% of all diabetics; impacts PERIPHERAL and AUTONOMIC NERVOUS SYSTEM!)
Term
Describe the impacts that DM has on the PNS and ANS
Definition

Vagal denervation occurs early and manifests as tachycardia, dysrhythmias, and loss of heart rate variability seen with DB. 

 

Orothostatic hypotension is d/t autonomic neuropathy as a result of the SNS loss of vasoconstrictive capability; pt.'s have postural syncope, dizziness, and lightheadedness

Term
Autonomic neuropathies place patient at GREATER risk for developing...?
Definition
PAINLESS MYOCARDIAL ISCHEMIA!
Term
In diabetics with autonomic neuropathies, unexplained hypotension is a sign of a potential...?
Definition

MI

(WANT A 12 LEAD ASAP)

Term
True or False:  Diabetic Ketoacidosos is most commonly found in Type I diabetes?
Definition
True
Term
Most common trigger for DKA?
Definition
Infection
Term
Signs & Symptoms of DKA
Definition
  1. Lethargy and seizures (brain not getting enough glucose
  2. Ketone bodies in urine (fat breakdown=acetoacetate and B-hydroxybutyricate
  3. Tachypnea (to correct metabolic acidosis)
  4. N/V and SEVERE dehydration
  5. May present with very high serum K+; as corrected...significant hypokalemia!
Term
Acetoacetate and B-hydroxybutyricate both produce ______ gap   and ______acidosis?
Definition

Anion

Metabolic

Term
If pt. experiences DKA preoperatively, what are some anesthetic considerations?
Definition

? cancel case

or

possibility of DKA occuring in the OR (treatment:  fluids, IV insulin, tx anion gap)

Term
Preoperative anesthetic implications for diabetics
Definition
  • Routine tests (HgbA1C, CXR, 12 lead, lytes, BUN/Cr, etc.) RISK FOR SILENT MI
  • Significance of autonomic neuropathy and anesthesia (Diabetics with HTN have 50% chance of having diabetic autonomic neuropathy-INTRAOPERATIVE, post induction HYPOtension especially if on ACE inhibitors)
  • Gastroparesis-risk for aspiration
  • Renal dysfunction-Renal profile
  • Immobilization of joints (Prayer sign)-Glycosylation of tissue proteins produces stiff joints.  IMPLICATIONS:  Limited temporomandibular joint and cervical spine movement=difficult intubation
  • Oral antihyperglycemic meds (Gl- names have LONG 1/2 lives and are discontinued 24-48 hours before surgery
  • Insulin therapy during their hospitalization
Term
Glucophage in the presence of _______ can potentiate renal failure?
Definition

HYPOVOLEMIA (Also, consider: 

glucophage+NPO+IV contrast dye=RF)

Want to HYDRATE and monitor Renal profiles

Term
Autonomic neuropathy of the parasympathetic NS
Definition

Vagal denervation leads to:

  • Tachycardia
  • Arrhythmias
  • Loss of heart:lung variability
  • Delayed gastric emptying
Term
Autonomic neuropathy of sympathetic NS
Definition
  • Orthostatic hypotension
  • Dizziness
  • Lightheadedness
Term
M & M states what percentage of diabetic patients are unaware of their condition?
Definition
33-50%
Term
True or False:  In diabetics, morbidity is related to pre-existing end organ damage
Definition
True
Term
Intraoperative anesthetic considerations
Definition
  • Goal BS<180mg/dl
  • Specialty case considerations (neuro and ischemic heart cases-glucose extends the pnumbra which is the area of tissue that is in trouble but still salvageable)
  • Pregnancy must have good sugar control to improve fetal outcome
  • Poor insulin SQ uptake in the OR (hypothermia); GIVE IV INSULIN
  • 1/2 dose patient regimen
Term
Calculation for OR intravenous dose of insulin
Definition

KNOW:  1 unit of REGULAR insulin will decrease the plasma glucose by 25-30 mg/dl

 

Continuous Infusion:  1 unit/ml (100ml bag contains 100 units); Start infusion at 0.1units/kg/h

 

Quick & Dirty:  Units per Hour=Plasma Glucose (mg/dl)

                                          150

Term
Short-Acting Insulins
Definition

Onset, Peak Action, Duration

  • Lispro (10-20min, 30-90min, 4-6hrs)
  • Regular (15-30min, 1-3hrs, 5-7hrs)
  • Semilente, Semitard (30-60min, 4-6hrs, 12-16hrs)
Term

Intermediate-Acting Insulins

 

Definition

Lente, Lentard, NPH

Onset-2 to 4 h

Peak Action (TIME TO RECHECK in OR)-8 to 10h

Duration-18 to 24h

Term
Long-Acting Insulins
Definition

Ultralente, Glargine, Insulatard

 

Onset-4 to 5 h

Peak Action (TIME TO RECHECK in OR)-8 to 14h

Duration-25 to 36h

Term
Surgical procedures are stressful.  Patients usually (increase/decrease) their blood glucose d/t release of cortisol and catecholamines? (choose one)
Definition
Increase
Term
What two things must you know concerning administration of insulin on the day of surgery?
Definition
  1. Peak action of insulin administered
  2. Amount of insulin administered
Term
What amount of time does M & M suggest intraoperative glocometer monitoring?
Definition
Every 2-3 hrs while in the OR.  Report to PACU if they should repeat.
Term
What substance in NPH Insulin can cause the production of antibodies potentiating a possible anaphylactic reaction?
Definition

Protamine

HAVE backup meds ready to treat anaphylaxis (Epi, benadryl, pepcid, steroids, etc...)

(Small test dose should be administered-1mg slowly and close monitoring of blood pressure as well as other signs of anaphylaxis)

 

Term

Diabetic patients are at such high risk of suffering from autonomic neuropathy (or the anesthetist is HIGHLY suspicious)...ALWAYS monitor (3 vs. 5) lead? (choose one)

 

Definition
5
Term
How do we decide if pt is RSI?
Definition
  • Some practitioners determine "risk of aspiration" based on:
  1. How long diabetic condition has existed
  2. Insulin vs. non-insulin dependence
  3. Other autonomic neuropathy symptoms
Term
RSI error on the side of caution-what two drugs can be administered to help manage risk for aspiration?
Definition

Bicitra-nonparticulate antacid

Reglan-prokinetic; increase GI motility

Term

Why is ESRD a complicating factor when considering RSI?

 

Definition
Elevated K+ levels and the use of succs.  May need to use rocuronium (LONGER acting)
Term
Most COMMON indicators of hypoglycemia
Definition

Diaphoresis with tachycardia

(A vigilant provider should be suspicious and check blood sugar to rule out hypoglycemia as the cause)

Term
Hypoglycemia is glucose level
Definition
<50mg/dl in and ADULT
Term
General anesthesia (enhances/blunts) most identifiable symptoms associated with hypoglycemia? (choose one)
Definition
Blunts
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