This document provides guidance on peri-operative management of diabetes patients. It discusses:
1. Pre-operative assessment including glycemic control evaluation and general health assessment.
2. Management for minor and major elective surgeries, including insulin adjustments and use of glucose-potassium-insulin infusions or variable rate intravenous insulin infusions.
3. Management for emergency surgeries and post-operative care focusing on glycemic control and fluid/electrolyte balance.
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Case studies in the managment of type 2 diabetes NasserAljuhani
Case 1:Poorly controlled type 2 diabetes on triple oral therapies
Case 2:Morning hypoglycemia on premixed InsulinCase 3
Case 3:Newly diagnosed D.M Type1D.M or type 2 D.M ?
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Case studies in the managment of type 2 diabetes NasserAljuhani
Case 1:Poorly controlled type 2 diabetes on triple oral therapies
Case 2:Morning hypoglycemia on premixed InsulinCase 3
Case 3:Newly diagnosed D.M Type1D.M or type 2 D.M ?
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/h3HRvWGUj5A
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Diabetes is fast gaining the status of a potential epidemic in India with more than 65 million diabetic individuals currently diagnosed with the disease. Ranked second in the world, the burden of the disease is expected to compound in the years to come. Worryingly, diabetes is now being shown to be associated with a spectrum of complications and to be occurring at a relatively younger age within the country.
It is a known fact that most of the diabetes cases in our country is managed by primary care Physicians(PCP) who have a pivotal role to play in ensuring that diabetes patients receive effective care by practicing evidence based management. This said, the sad fact is that health care providers-primary care and specialists alike are not managing our patients with diabetes as well as we should be.
The complexities of the disease and its association with lot of other medical conditions make the management of diabetes more challenging to the PCPs. Patients feeling of frustration and denial about having the chronic condition often are a challenge to the practitioners in convincing the patients for initiation of treatment. With no clear cut national policy guidelines for management of diabetes, we rely on western guidelines which have certain pitfalls and fallacies in our setting.
Insulin intensification : the usage of premixed insulin after basal fails mataharitimoer MT
Insulin intensification : the usage of premixed insulin after basal fails
EDDY SUPRIADI, MD | MARZOEKI MAHDI , MD. HOSPITAL.BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Practical guide to insulin therapy in primary health care.
Types of insulin (basal-bolus, pre-mixed)
Insulin regimens (augmentation, total replacement)
How to convert from one insulin type to another.
Some challenging cases.
Etiopathogenesis and pharmacotherapy of hyperlipidemias
a. the pathophysiology of selected disease states and the rationale for drug therapy;
b. the therapeutic approach to management of these diseases;
c. the controversies in drug therapy;
d. the importance of preparation of individualised therapeutic plans based on diagnosis;
e. needs to identify the patient-specific parameters relevant in initiating drug therapy,
and monitoring therapy (including alternatives, time-course of clinical and laboratory
indices of therapeutic response and adverse effects);
f. describe the pathophysiology of selected disease states and explain the rationale for
drug therapy;
g. summarise the therapeutic approach to management of these diseases including
reference to the latest available evidence;
h. discuss the controversies in drug therapy;
i. discuss the preparation of individualised therapeutic plans based on diagnosis; and
j. identify the patient-specific parameters relevant in initiating drug therapy, and
monitoring therapy (including alternatives, time-course of clinical and laboratory indices of therapeutic response and adverse effects).
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/h3HRvWGUj5A
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Diabetes is fast gaining the status of a potential epidemic in India with more than 65 million diabetic individuals currently diagnosed with the disease. Ranked second in the world, the burden of the disease is expected to compound in the years to come. Worryingly, diabetes is now being shown to be associated with a spectrum of complications and to be occurring at a relatively younger age within the country.
It is a known fact that most of the diabetes cases in our country is managed by primary care Physicians(PCP) who have a pivotal role to play in ensuring that diabetes patients receive effective care by practicing evidence based management. This said, the sad fact is that health care providers-primary care and specialists alike are not managing our patients with diabetes as well as we should be.
The complexities of the disease and its association with lot of other medical conditions make the management of diabetes more challenging to the PCPs. Patients feeling of frustration and denial about having the chronic condition often are a challenge to the practitioners in convincing the patients for initiation of treatment. With no clear cut national policy guidelines for management of diabetes, we rely on western guidelines which have certain pitfalls and fallacies in our setting.
Insulin intensification : the usage of premixed insulin after basal fails mataharitimoer MT
Insulin intensification : the usage of premixed insulin after basal fails
EDDY SUPRIADI, MD | MARZOEKI MAHDI , MD. HOSPITAL.BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Practical guide to insulin therapy in primary health care.
Types of insulin (basal-bolus, pre-mixed)
Insulin regimens (augmentation, total replacement)
How to convert from one insulin type to another.
Some challenging cases.
Etiopathogenesis and pharmacotherapy of hyperlipidemias
a. the pathophysiology of selected disease states and the rationale for drug therapy;
b. the therapeutic approach to management of these diseases;
c. the controversies in drug therapy;
d. the importance of preparation of individualised therapeutic plans based on diagnosis;
e. needs to identify the patient-specific parameters relevant in initiating drug therapy,
and monitoring therapy (including alternatives, time-course of clinical and laboratory
indices of therapeutic response and adverse effects);
f. describe the pathophysiology of selected disease states and explain the rationale for
drug therapy;
g. summarise the therapeutic approach to management of these diseases including
reference to the latest available evidence;
h. discuss the controversies in drug therapy;
i. discuss the preparation of individualised therapeutic plans based on diagnosis; and
j. identify the patient-specific parameters relevant in initiating drug therapy, and
monitoring therapy (including alternatives, time-course of clinical and laboratory indices of therapeutic response and adverse effects).
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Diabetes in surgery (evidence based management protocol)Hriday Ranjan Roy
25% diabetic patient need surgery. He or she may have surgical disease along with diabetes or diabetes may complicate to surgical conditions. So it is critical to manage diabetes during surgical events.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. Peri-operative diabetic control
Aims : maintain good glycemic control throughout
: maintain normal electrolyte concentrations
: optimize intra-operative cardiovascular and renal function
to reduce the post operative complications and mortality
2
3. General guidance
Modern management of the surgical patient with diabetes
focuses on:
- thorough pre-operative assessment
- optimization of glycemic control
- careful intra-operative and post operative management
3
4. Types of surgery
Minor surgery means:
- day case or overnight stay, likely to resume normal
oral intake within 12 hours (missing only one meal)
Major surgery means:
- unlikely to resume normal intake more than 12 hours
(missing 2 meals or more)
4
5. Pre operative assessment for Diabetes Mellitus
1. General Assessment
- presence of cardiac, renal and neurological sequelae of Diabetes
2. Assessment of Glycemic control
- Desired preoperative HbA1C is < 8.5% (8 - 9% is acceptable
depending on individual)
- Recommended target : 4 - 6 mmol/L (pre meal) and < 10 mmol/L
(2HPP)
5
6. Elective surgery
(a) Minor surgery
Patients on diet alone or oral hypoglycemic agents ( OHA)
- Omit OHA on the day of the operation
- Check capillary blood glucose before and after the operation
- If blood glucose is 4 -10 mmol/L (70-180mg/dl), simple
observation is required
-If blood glucose is > 10mmol/L (180mg/dl), consider the
need for glucose-potassium-insulin infusion(GKI) or variable
rate intravenous insulin infusion ( VRIII )
-If blood glucose <4mmol/L (70mg/dl), treat as
hypoglycemia
-Restart OHA after the operation once the patient has had the
first meal 6
7. Elective surgery
Patients on insulin
Omit morning insulin on the day of the operation
Check capillary blood glucose before and after the operation
- If blood glucose is 4 - 10 mmol/L (70-180mg/dl), simple observation is
required
-If blood glucose is >10mmol/L (180mg/dl), consider the need for glucose-
potassium-insulin infusion(GKI) or variable rate intravenous insulin
infusion ( VRIII )
-If blood glucose < 4mmol/L (70mg/dl), treat as hypoglycemia
-Restart usual insulin and diet after the operation
7
8. Elective surgery
(b) Major surgery
Patients on diet alone or OHA
Omit OHA on the day of the operation
Commence GKI or VRIII 2 hours before the operation
Monitor the blood glucose hourly pre, intra and post operatively
Stop GKI or VRIII and restart the usual medication only when the
patient is eating and drinking normally
8
9. .Patients on insulin
Omit subcutaneous soluble or rapid acting insulin and mixed insulin on the
day of the operation
Long acting (basal; Glargine) insulin is usually continued at normal time even
when the patient is on GKI or VRIII
If the surgery is planned in the evening and patient is having breakfast,
administer half the normal breakfast insulin
Commence GKI or VRIII two hours before the operation
Monitor blood glucose hourly pre, intra and post operatively
If blood glucose < 4 mmol/L (70mg/dl), treat as hypoglycemia
When the patient is eating and drinking normally, start normal dose of insulin
with the first meal and stop the GKI or VRIII 60 minutes later
9
10. Emergency Surgery
There will be no opportunity for pre admission planning
If the blood sugars are > 250 mg/dl and signs of
decompensation (acidosis, hypotension), check urine/blood
ketones /electrolytes
If ketones is positive, postpone operation , refer to physicians
and treat as DKA
If blood sugars rises above 10mmol/L(180mg/dl) , GKI or
VRIII should be commenced and continued until the patient
finishes operation and starts eating and drinking
10
11. Post operative care
Aims
Ensure the glycemic control, fluid and electrolyte balances are
maintained
Aim for capillary blood glucose level in the 5.6 -10 mmol/L (100-
180mg/dl) where this can be achieved safely
Monitor the fluid and electrolyte daily and prescribe appropriate
fluid
Encourage an early return to normal eating and drinking,
facilitating return to usual diabetes regimen 11
12. Glucose-Potassium-Insulin infusion (GKI)
GKI infusion avoid the risk associated with running IV
glucose and IV insulin through separate lines
If one canula becomes blocked, the patient may become
hypo- or hyperglycemia.
However GKI infusions are not suitable in poorly
controlled diabetes or patients who are very unwell
(where close serum glucose monitoring is required)
12
13. Take a 500ml of 10% glucose and add soluble insulin according
to the table below
The insulin should be injected into the bag according to
following table and mixed thoroughly
Add 10 -20 mmol of KCl (Note: omit KCL if patient has renal failure or
pre-op: K+ > 5mmol/L)
13
Blood glucose
mmol/L (mg/dl)
Insulin (units) in
each
500 ml bag
Serum potassium
(mmol/L)
KCL to be added
(mmol/bag)
<4 (<70) Treat as
hypoglycemia
<3 20
4-6 (70-110) 6 3-5 10
6-10 (110-180) 10 >5 None
10-20 (180-360) 15
>20 (360) 20
14. Run infusion at 100ml/hr
Target glucose 5.6 -10 mmol/L (100 -180 mg/dl)
Each change in units of insulin per bag requires a new bag
It is not acceptable to allow blood glucose levels to be
consistently > 10 mmol/L (180 mg/dl) and hypoglycemia < 4
mmol/L (<70 mg/dl) should be avoided
If the patient has significantly impaired renal function (eGFR
< 30), the patient may need a reduced insulin dose or a reduced
infusion rate
14
15. The patient who is insulin resistant (obese, infection, steroid
therapy) needs more insulin (2-6 more units)
The pre-, intra and post-op blood glucose is stable, the post-op
blood glucose may be checked 2 hourly
Change to subcutaneous insulin when eating normally. It is
important to continue the IV insulin infusion for 60 minutes
after the first subcutaneous insulin injection has been given
15
16. Variable rate intravenous insulin infusion (VRIII)
This is alternative to the GKI infusion, which is more suitable and practical
for very ill patients peri- or post-operatively
It involves separate infusion of glucose and insulin in two different lines
Target glucose 5.6 -10 mmol/L (100 -180 mg/dl)
It is not acceptable to allow blood glucose levels to be consistently > 10
mmol/L (180 mg/dl) and hypoglycemia < 4 mmol/L (<70 mg/dl) should be
avoided
16
17. VRIII
Insulin preparation
A 50 ml syringe with 50 units of soluble insulin with 49.5 ml of 0.9%
sodium chloride solution (syringe pump )
A 250 ml of 0.9% sodium chloride solution with 250 units of soluble insulin
(infusion pump/flow meter)
A 500 ml of 0.9% sodium chloride solution with 25 units of soluble insulin
(7 drop/min = 1 unit/hr )
- Dose adjustment by monitoring RBS hourly
17
18. Rate of VRIII
Initial dose and subsequent adjustment can be done according
to variable scale depending on RBS level and response to
insulin as follow.
Capillary blood
glucose
Reduced Rate Standard Rate Increased Rate
< 70 mg/dl Inpatient hypoglycemia
policy
Inpatient
hypoglycemia policy
Inpatient hypoglycemia
policy
70-109 mg/dl 0 unit 0 unit 0 unit
110-144 mg/dl 0.5 unit 1 unit 2 units
145-214 mg/dl 1 unit 2 units 4 units
215-289 mg/dl 2 units 4 units 6 units
290-360 mg/dl 3 units 5 units 7 units
361-435 mg/dl 4 units 6 units 8 units
> 435 mg/dl 5 units 8 units 10 units
19. Rate of VRIII
Reduced rate - insulin sensitive patients (i.e. < 24 unit/day),
lean or elderly patients or low basal or meal insulin doses
Standard rate - use unless otherwise indicated
Increased rate - insulin resistant patient (i.e. >100 unit/day),
patient on steroids, TPN, or tube feeding
or high basal or meal insulin doses
19
20. Substrate infusion
Fluids to run alongside the VRIII
5 -10 % dextrose water 500 ml and 10 mmol of KCl at a rate of 40
ml/hr
Check serum potassium daily
If K+ >5.5 mmol/L No KCl
If K+ 3.5-5.5 mmol/L 10 mmol of KCl
If K+ < 3.5 mmol/L 20 mmol of KCl
20
21. Discontinuation of insulin infusion
Patient tolerating at least 50% of normal oral intake
or enteral feeding
1 or 2 hours before discontinuing the insulin infusion,
initiate alternative glycemic management
21
27. Risk factors for diabetes nephropathy
Hypertension
Hyperglycemia
Microalbuminuria
Duration of diabetes
Family history
Ethnicity
Cigarette smoking
Hyperlipidemia
27
28. Screening for microalbuminuria
Test for microalbuminuria annually in all type 2 diabetes
subjects starting at diagnosis
Type 1 diabetes of more than 5 years duration
Methods
Measurement of the albumin to creatinine ratio in a random spot
collection
24 h collection with creatinine, allowing the simultaneous
measurement of creatinine
Timed collection
28
29. DM Nephropathy
presence of dipstick +ve proteinuria in a
person with diabetes ( >300mg/day )
Incipient nephropathy
Urinary ACR 2.5 -30mg/mmol (men)
3.5-30mg/mmol (women)
Urine microalbumin 30-300 mg/24 hour
20-200microgram/min
31. CKD and anti-diabetic drugs
Biguanides – contraindicated if eGFR <30; reduce dose if eGFR is
between 30-45
Sulphonylureas are best avoided; shorter acting agents like glipizide
and gliclazide may be used in mild to moderate renal insufficiency
Repaglinide is safe in kidney failure
Glitazones and acarbose are best avoided
Sitagliptin, saxagliptin and vildagliptin can be given with dose
adjustment and linagliptin can be used without dose adjustment
Insulin is the antidiabetic agent of choice; regular insulin and rapid
acting analogues are preferred 31
32. Blood pressure control in CKD
The ADA states that all patients with diabetes should aim to
keep their BP <140/90 mm Hg
However, individuals with proteinuria may be candidates for
tighter BP control, if this can be achieved without significant
side effects
Drugs blocking the Renin Angiotensin Aldosterone System
(RAAS) are the antihypertensive agents of choice.
ACEI or ARB : should be the first choice
ACEI can be used even serum creatinine rise above 200 mg/dl
providing that patient is planned for dialysis
Dual therapy is not advisable because of hyperkalemia
32
33. Others
Protein restriction can reduce hyperfiltration and
intraglomerular pressure
0.8mg/kg/day RDA is recommended by ADA
Salt restriction is advisable
Avoid nephrotoxic drugs, eg : NSAID
Stop smoking
Aggressive treatment of UTI
Lipid lowering therapy : Statins can reduce CVD risk but
reduce dose of rosuvastatin
Refer to Nephrologist if EGFR < 45 and Joint care is utmost
important
33