1. -DM type I= no insulin; DM type II= some insulin is present, but cells do not uptake the glucose. - Hyperglycemic Hyperosmolar Syndrome(HHS) has little or NO acidosis, Glucose more then 1000mg/dL and hyperosmolar; DKA has normal osmolarity, acidosis, and glucose of more then 250-800mg/dL. HHS is more common in type 2 DM, DKA is more common in type 1 DM. - HSS has sever Hyperglycemia--->osmotic diuresis(suck blood from intracellular compartment to the intra-vascular)---> urinary excreation ---> Sever Dehydration and water loss---> Hyperosmolar state usu. more then 320 mOsm/kg---> CNS deterioration(even coma in 20%). -In HHS the limited insulin is enough to limit the production of ketones from the liver. -DKA has no insulin--->increased ketones---> Acidosis---> increase Anion Gab in moderate & sever cases. -MCC of stress leading to DKA or HHS is infection. -High endogenous sec. insulin= high c-peptide level - Diabetic S/S Rx: Gastrointestinal neuropathy(= orthostatic postural orthostasis, postprandial hyo-glycemia) Rx. I. Small frequant meals, II. Erythromycin. III. Cisapride Neuropathic pain Rx.: I. Amitriptyline
2. 1st: Cardiac Monitor & NPO & NS 0.9%(IV) & Regular Insulin(IV) & ICU admission(Vitals Q15 min + BMP & ABG Q 2 hours) 2nd: -@ Glucose level of 250mg/dl Change NS 0.9% to D5 0.45%(IV) that contain K+ of 20-40 mEq/l. - give KCl(IV) if K+ is with in normal limits - give HCO3(IV) if pH is less then 6.9 - After stabilisation, and normalization of the anion gap, and electrolyte move from ICU to word & add Insulin (SC) & Keep both insulin (IV) to (SC) for 60 minutes, then D/C insulin(IV) and continue with Insulin (SC) only.
3. Hyper=S/S Polyphagia+polydipsia+polyuria+ Dehydration+Fatigue+ weight loss= MCC is DM
   1. Medications
      1. Rx. I. Exercise & Diet
      2. Rx. II. Hypoglycemics (PO)
      3. III. Insulin (IV)
         1. very short acting
            1. Lispro
            2. Control sugar of a meal
         2. short acting
            1. Regular
         3. long acting
            1. NPH or glargine
            2. Control sugar between meals
         4. Insulin pump is better then lispro & Glargine
   2. S/S w/ an 8-hour fasting serum glucose level of 126 mg/dl more
      1. Dx. DM type 2
         1. Variable S/S CNS depression+glucose 250-1000 mg/dL+Ketones in urine & serum + pH less then 7.30+Osmolality is variable+anion gap more then 10+ bicarbonate less then 18 mEq/L
            1. Dx. DKA
         2. Prominent S/S CNS depression+glucose more then 600+little ketones+pH more then 7.30+Osmolality more then 320+anion gap is variable+ Bicarbonate is more then 18
            1. Dx. HHS
   3. S/S w/ Random glucose measure of 200 mg/dl
   4. S/S w/ Oral glucose tolerance test (OGT) of more then 200 mg/dl measured after 2 hours of taking 75gm of glucose load
4. No S/S (eg: job screening)
   1. 2 positive tests (OGT, Random, or fasting) must be done during 2 different days
5. HYPO=S/S Tachycardia + sweating + CNS (Headache, anxiety,,) + Hunger=MCC is Anti-DM Rx
   1. Rx. I. Sugar (PO), II. D5% III. D10%
      1. Acute cause
         1. IV. Glucagon(SC) or Somatostatine(IV)
      2. prolonged duration of Hypoglycemia = Sulfanoylureas
         1. IV.Octeotide (SC)
   2. Inv. Insulin & C-peptide levels
      1. Increased C-peptide
         1. Hx. of Access to Rx.
            1. Dx. Sulfanoylureas abuse
            2. confirm with Sulfanoylurea in Bl/Urine
         2. Dx. Insulinoma
            1. Rx. Surgery
      2. decrease C-peptide
         1. Dx. Insulin Rx. Abuse