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114 Cards in this Set
- Front
- Back
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When does DKA occur time wise
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MUST onset more acute
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What does HHS
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over weeks
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What type of DM does DKA occur in
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Type 1
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What is DKA
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absolute insulin deficeny with increase in STRESS hormone
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What are the 3 major components to DKA
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Hyperglycemia >250
Acidosis <7.35 KETONES |
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What are glucose values in DKA, and water deficet
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Glucose 250-500 <600
Water deficent 4-6 L |
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What are glucose values in HHS (MAINLY in TYPE II )and water deficient
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Glucose >HIGH -->600 and >10000
and have 10-12 Liter difiecnt |
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What are signs and symptoms HHS
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HIGH glucose values
Dehydration (10-12) NO KETONE (or small) Less acidoic |
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What are the typical S/S of DKA
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BG >2500
Ph <7.35 Ketones Kussmual respirtations Polyuria, Polydispia, and N/V, abdominal pain |
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What led to the pts DKA
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Infection (number 1 cause
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IN DKA you have an insulin deificne and increase release of coutner regulatory hormones, which to LIPOLYSIS, which what happen
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Release of Glycogen and FFGA
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What do the FFA do
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go to the liver become oxidated,a dn become KETONES
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What are the 3 types of KETONES
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Acetoacetate
Acetone Beta-Hydroxbutrate |
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What do KETONE are acids
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Acetoactetate and Beta-hydroxbutrate
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What ketone is neutral, and has the fruity smell
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acetone (DOES NOT contribute to acidosis)
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What is the MAIN ketone produced, and do you test for
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Beta hydroxbutarte--NO not generally
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What ketone do you test for in the blood and urine
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acetoacetate
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What are OTHER cuases of DKA
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Noncomplicane, STROKE Or STRESS
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What determines severity
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Ph
Bicarb Anion gap MENTAL STATUS NOT GLUCOSE or KETONE |
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Patient with an alter mental status, have what type of DKA
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SEVERE DKA
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What is the MAIN broad treatment of DKA
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Fluids
Insulin Electrolytes |
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How fluid deficent are pts with DKA, and wht
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4-6 fluid liter down b/c of osmotic diuersis
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What is the FLUID OF CHOICE and how to START
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START BOLUS 15-20ml/kg of NS for 1 hour
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What is the typical dose of NS given as a BOLUS
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1-2 L
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After the bolus of NS, what is maintence fluide
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250-500 ml/hr until replete 6-10 L
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When would you SWITCH to 1/2NS after inital bolus
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correct SODIUM is NORMAL or elevated
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When is appropraite to continue NS
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is correct NA is low
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What is mainetence dosing of 1/2NS
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250-500ml/hr
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How do correct sodium
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Subtract 100 from glucose
1.6 X every per 100 glucose over (ie 410--x by 4 |
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In this pt what was the appropriate fluid administration
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BOLUS NS, then switching to NS b/c NORMAL
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Once you BG reach 250 what do you do
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ADD on Dextrose to prevent hypogyemia, and allowing you to continue to give inuslin as they are fluid deficient
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What is the preferred type of insulin
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REGULAR isulin
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What is the preffered dosing of INSULIN
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0.1 units/kg BOLUS, then infusion 0.1 units/kg/hr
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0.1 units/kg BOLUS, followed by 0.1 units/kg/hr SEEM like a LOT of insulin, what NOT but
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insulin deficent
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How fast do you want to drop BG
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50-70 mg/dl per HR until normal range
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Why dont we want to DROP BG too FAST
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Cerebral edema---
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How could cerbral edema occur
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Glucse can drop fast in the body, but takes longer for it to drop in the brain due to the BBB, so water will rush into the brain and cuase edema
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Why does HHS more like result in cerebral edema
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pts have much higher glucose levels
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What electrolytes inbalance do you we worry about the MOST
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K
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Why do pts often LOOK hyperkalemia, but are NOT
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Potassium shirt out of the cells
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When should you give K+ replace
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once drops below 5
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Once we start fluids will are electrolytes DROP
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YES
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The fast wer give glucose what will happen
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the faster will we DROP electrolytes
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Why do total body electrolytes appear NORMAL, why are they not
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THEY are low, b/c the extraceullar shits
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How can we give K+
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central of peripheral LINE
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When do we give K+ before INSULIN
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K<3.3
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Can you give K BOLUS?
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NO it will STOP THE HEART
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What is dosing of K, peripheral line (NEED 60-80-meq)
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10 meq/hr
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What is dosing of K, central line
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20 meq/hr MAX
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What is the ROLE of magnesium
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helps body use K more efficently
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What is dosing of Mg
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2gm/hr
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What is the role of phosphate
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required for ATP--and don't have enough you will energy issues
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How do you replace phosphate
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5mmole/hr
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WHat are the ENDPOINTS YOU ARE LOOKING FOR
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Anion Gap <12
Decrease Acdmia ph >7.3, Bicarb 18 or greater Improvement in mental satus |
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ONCE YOU REACH THE ENPOINTS 1st ahve the patient START
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eating
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Once the pt starting eating, then what do you do
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START GLARGINE OR NPH
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How long do you over Glargine or NPH with the insulin infusion
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1-2 hours
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What are the 2 organs that regular acid in our body
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LUNGS and KIDNEYS
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What do the lungs regulate
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PCO2
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What do the kidney regulate
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BICARB
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How do calculate an anion gap
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Na- (Cl + CO2)
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And what level is ANION gap
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>12
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What are causes of anion gap metabolic acidosis
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Menthanol
Uremia DKA Paraldehyde Iron, isoniazide Latic acidosis Ethelee glycol Salsilates |
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What are the components of an ABG
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pH/pCO2/pO2/HCO3
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What is normal ph
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7.35 to 7.45
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What is a NORMAL pCO2
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38-42`
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What is NORMAL bicarb
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22-26
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What does a pH tell us
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acidosis or alkalosis
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What does PCO2 tell us
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tells us the respiratory fxn
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What does the p02 (80-100_
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tells the repiratory people getting enough oxygen
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What does Respiraoty acidosis LOOK LIKE
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Decrease pH, increase pCO2, and a compenstary increase in HCO3, b/c the kidne are hold bicarb
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What does Metabolic acidosis LOOK
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Decrease pH, decreased HCO3, and a compenstory decrease in PCO2, and llungs are breathing off acid
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How do you tell if it is metabolic
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ALL arrows are GOING either UP or DOWN
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How do you tell if it is repiratory
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PH is DOWN, and all other up
PH is UP, and all other are DOWN |
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What is the compenstaory method is DKA
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lugns are compensating
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What is SIRS
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sysyemic inflammaotry response syndrome
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SIRS is your bodys nautral response to INFECTION what are the 4 components
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TEMP, HR, RR, and WBC
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What are the 4 componets of SIRS
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TEMP >38 or <36 C
HR >90 RR >20 or pCO2 <32 WBC >12,000 <4000 or >10% bands |
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How many to do NEED for SIRS
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2 or more
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What is SEPSIS
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SIRS + infection (2 of SIRS plus SS or infection)
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What is SEVERE SEPSIS
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SEPSIS + organ dsyfucntion
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What is consider organ dysduction
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ON ventalition, have ARF, heptic failure or metabolic acidosis!!!
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What is septic shock
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SEVERE hypotenion despite adequate fluid nessiations
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What is the MAIN treatment of septic shock
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1. FLUIDS NS---must fill up the bucket and reperfuse the vital orgals
2. TREATMENT OF INFECTION (MAIN)!!!!!! |
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What are risk factors for yeast infection
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1. Broad spectum antibiotics
2. Central venous catheter 3. TPN 4. Neutropenia 5. Immunosupprive durg 6. ICU or Dialysis |
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Before treatment of candida what do you do FIRST
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REMOVE as many risk factors as we can
stop antibiotics, pull out catheter, PTN |
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What is the MOST common Candida
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candida albcins
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What test determines the presence of Candida albicans
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Germ Tube test
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If the germ tube test is + it tells up
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candia albinca
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How do you determine how to treat candida infection
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decide base on how sick your are, and ythe susceptible and the MOST common in your ICU
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What are the choice for treatment of candida infection
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Fluconazole, Echinocancine, Ampo B, or Vorciconazole
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How do you pcik
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LOOK at what they cover, and ORGAN function
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WHat does FLuconazole cover
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Candida albican and paracipolis
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What does fluconazole MISS
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glabrata and krusei
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What is doing of Fluconzole
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800mg load, then 400mg qd
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400mg qd is apporopriate for S candida, what is best for SDD
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800mg qd
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When do you dose adjust for fluconazole
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CrCl <30
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Voriconazole does NOT add a lot compared to fluconzole, what does it cover
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Krusi
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Does voriconzole cover glabrata, and why bad
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2nd most common candida in ICU
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What is BAD about the IV form of voriconazole
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contain cyclodextrin which has been shown to cause renal toxicty in animal
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What are the 3 types of enhinocandins
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Mica, Anidular, Caspofungin
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What are the BEST agents for candida
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Enchinodins
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When are the ecinocandins preffered
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moderate to severe illness or RECENT azole exposure
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Why are the enchinocaninds prefffered
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BORADER spetum
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NO difference between echinocandins, how do you make choie
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based on COST and PK
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What are the properites of Anidulafun
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Cleared in blood, does not intearct with cyclospinre, and MOST expensive, and NO dose adjustment
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Both Micafungin and Caspfungin must be dose adjusted in heaptic dysfunction, which one has MOST drug interactions
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Micafungin
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AMB can be used last line what are its MAJOR SE htat limit its use
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Nephrotoxicty, infusion related reactioan and electrolyte abnormalits
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What is the preferred AMB agent
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Ambisone or albect
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What is the treatment duration of CANDIDA infection (MUST KNOW)
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treatment for 2 weeks PAST a negative blood culutes
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What are monitoring for with Candida
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S/S of improvement
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What do you do if drug has failed treatment with candida
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PULL cathers look where the bug is sticking
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Should you switch to fluconzole if found out bug is cnadida albicans
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YES
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If fluconazole is SDD, what do you need to do
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HIGHER dose b/c of the intermiedate susceptiblity
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