endocrine and metabolic disorders
Diabetes Mellitus (DM)
Special Populations and Settings
Diabetes care requires careful adjustment for patient factors, including those related to age and lifestyle, comorbid conditions, and need for treatment of other acute or chronic conditions. production is almost completely absent, and in some patients, counter-regulatory response to hypoglycemia is impaired. Other causes of labile plasma glucose levels include occult infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrine disorders (eg, Addison Disease ). Patients with chronic difficulty maintaining acceptable glucose levels should be evaluated for situational factors that affect glucose control. Such factors include inadequate patient education or understanding that leads to errors ininsulinadministration, inappropriate food choices, and psychosocial stress that expresses itself in erratic patterns of medication use and food intake. The initial approach is to thoroughly review self-care techniques, includinginsulinpreparation and injection and glucose testing. Increased frequency of self-testing may reveal previously unrecognized patterns and provides the patient with helpful feedback. A thorough dietary history, including timing of meals, should be taken to identify potential contributions to poor control. Underlying disorders should be ruled out by physical examination and appropriate laboratory tests. For someinsulin-treated patients, changing to a more intensive regimen that allows for frequent dose adjustments (based on glucose testing) is helpful. Continuous glucose monitoring with alarms and sensor-augmented or hybrid closed-loopinsulinpump therapy are useful tools in individuals who fluctuate between hypoglycemia and hyperglycemia. Diabetes Mellitus in Children and Adolescents is discussed in more detail elsewhere. replacement as do adults, and similar treatment regimens, including Insulin pumps , are used. However, the risk of hypoglycemia, because of unpredictable meal and activity patterns and limited ability to report hypoglycemic symptoms, may require modification of treatment goals. Most young children can be taught to actively participate in their own care, including glucose testing and Children with type 2 diabetesrequire the same attention to diet and weight control and recognition and management of dyslipidemia and hypertension as do adults. Most children with type 2 diabetes have obesity, so lifestyle modification is the cornerstone of therapy. Medication therapy may also be indicated. Diabetes Mellitus in Children and Adolescents is discussed in more detail elsewhere. Glucose control typically deteriorates as children with diabetes enter adolescence. Multiple factors contribute, including Pubertal andinsulin-induced weight gain Hormonal changes that decreaseinsulinsensitivity Psychosocial factors that lead toinsulinnonadherence (eg, mood and anxiety disorders, hectic schedules, irregular meals, family conflict) Experimentation with cigarette, alcohol, and substance use Introduction to Eating Disorders that lead to For these reasons, some adolescents experience recurrent episodes of hyperglycemia, Diabetic Ketoacidosis (DKA) , and hypoglycemia requiring emergency department visits and hospitalization. Treatment often involves intensive medical supervision combined with psychosocial interventions (eg, mentoring or support groups), individual or family therapy, and psychopharmacology when indicated. Patient education is important so that adolescents can safely enjoy the freedoms of early adulthood. Rather than judging personal choices and behaviors, clinicians must continually reinforce the need for careful glycemic control, especially frequent glucose monitoring and use of frequent, low-dose, fast-actinginsulinsas needed. Diabetes mellitus may be a primary reason for hospitalization or may accompany other illnesses that require inpatient care. All patients with Diabetic Ketoacidosis (DKA) , When other illnesses mandate hospitalization, some patients can continue on their home diabetes treatment regimens. However, glucose control often proves difficult, and it is often neglected when other diseases are more acute. Restricted physical activity and acute illness worsen hyperglycemia in some patients, whereas dietary restrictions and symptoms that accompany illness (eg, nausea, vomiting, diarrhea, anorexia) precipitate hypoglycemia in others—especially when antihyperglycemic medication doses remain unchanged. In addition, it may be difficult to control glucose adequately in patients who are hospitalized because usual routines (eg, timing of meals, medications, and procedures) are inflexibly timed relative to diabetes treatment regimens. can cause Lactic Acidosis in patients with renal insufficiency and has to be stopped if contrast agents need to be given. Therefore, Most inpatients can be appropriately treated with basalinsulinwithout or with supplemental short-actinginsulin. Dipeptidyl peptidase-4 inhibitors are relatively safe, even in patients with kidney disease, and they may also be used for postprandial glucose lowering. Sliding-scaleinsulinshould not be the only intervention to correct hyperglycemia; it is reactive rather than proactive, and it leads to poor glycemic control compared to basal-bolusinsulin. Longer-actinginsulinsshould be adjusted to prevent hyperglycemia rather than just using short-actinginsulinsto correct it. Inpatient hyperglycemia is associated with increased infection rate and mortality. Critical illness causesinsulinresistance and hyperglycemia even in patients without known diabetes mellitus. Such stress-induced hyperglycemia is associated with poor outcomes, including increased mortality.Insulininfusion to maintain plasma glucose between 140 and 180 mg/dL (7.8 and 10.0 mmol/L) Prevents adverse outcomes such as organ failure Possibly enhances recovery from stroke Leads to improved survival in patients requiring prolonged (>5 days) critical care Previously, glucose target levels were lower; however, it appears that the less stringent targets as described above may be sufficient to prevent adverse outcomes. Severely ill patients, especially those treated with glucocorticoids or pressors and those receiving total parenteral nutrition (TPN), may need very high doses ofinsulin(>5 to 10 units/hour) because ofinsulinresistance. In critically ill patients or postsurgical patients who are in an intensive care unit,insulininfusion protocols and/or computerized algorithms can be used to titrateinsulindrips to maintain euglycemia. The physiologic stress of surgery can increase plasma glucose in patients with diabetes and induce Diabetic Ketoacidosis (DKA) in those with type 1 diabetes. For shorter procedures, subcutaneous Patients with type 2 diabetes who are takinginsulinshould be given 50% of their basalinsulindose the night or morning before surgery. An IV infusion of adextrosesolution can be started before surgery at a rate of 75 to 150 mL/hour and titrated to maintain euglycemia. During and after surgery, plasma glucose (and ketones if hyperglycemia suggests the need) should be measured at least every 2 hours.Dextroseinfusion can be continued, and regular or short-actinginsulincan be given subcutaneously every 4 to 6 hours as needed to maintain the plasma glucose level between 100 and 200 mg/dL (5.5 and 11.1 mmol/L) until the patient can be switched to oral feedings and resume the usualinsulinregimen. Additional doses of intermediate- or long-actinginsulinshould be given if there is a substantial delay (>24 hours) in resuming the usual regimen. This approach may also be used forinsulin-treated patients with type 2 diabetes, but frequent measurement of ketones may be omitted. Some physicians prefer to withhold subcutaneous or inhaledinsulinon the day of surgery and to giveinsulinby IV infusion. For patients undergoing a long procedure or major surgery, a continuousinsulininfusion is preferable, especially sinceinsulinrequirements can increase because of the stress of surgery. IVinsulininfusion can be given at the same time as intravenousdextrosesolution to maintain blood glucose. One approach is to combine glucose,insulin, andpotassiumin the same bag (GIK regimen), for example, by combining 10%dextrosewith 10 mEq (10 mmol)potassium, and 15 units ofinsulinin a 500-mL bag. Theinsulindoses are adjusted in 5-unit increments. This approach is not used at many institutions because of the frequent remixing and changing of bags needed to adjust to the patient's level of glycemia. A more common approach in the United States is to infuseinsulinanddextroseseparately.Insulincan be infused at a rate of 1 to 2 U/hour with 5%dextroseinfusing at 75 to 150 mL/hour. Theinsulinrate may need to be decreased for patients with moreinsulin-sensitive type 1 diabetes and increased for patients with moreinsulin-resistant type 2 diabetes. Ten percentdextrosemay also be used. It is important, especially in patients with type 1 diabetes, to continueinsulininfusion to avoid development of diabetes ketoacidosis.Insulinadsorption onto IV tubing can lead to inconsistent effects, which can be minimized by preflushing the IV tubing withinsulinsolution.Insulininfusion is continued through recovery, withinsulindose adjusted based on the plasma glucose levels obtained in the recovery room and at 1- to 2-hour intervals thereafter. Most patients with type 2 diabetes who are treated only with oral antihyperglycemic medications maintain acceptable glucose levels when fasting and may not requireinsulinin the perioperative period. Most oral medications, including sulfonylureas andmetformin, should be withheld on the day of surgery, and plasma glucose levels should be measured preoperatively and postoperatively and every 6 hours while patients receive IV fluids. Oral medications may be resumed when patients are able to eat, butmetforminshould be withheld until normal renal function is confirmed 48 hours after surgery. 