Small Ani. Med - Endocrine 6

drraythe's version from 2017-09-10 04:44

more DM

Question Answer
explain management of Non-ketotic hyperosmolar ptremember glucose has high osmotic pull, might cause idiogenic osmoles in brain. so for fluids Ensure adequate rate but generally slow rehydration to prevent cerebral edema. DONT give bicarb bc thats more osmolarity. give insulin q1h or CRI, Monitor potassium and supplement if in the normal range and start giving fluids.
benefit of at home monitoring? explain it home= less stress= less falsely elevated bc stress (remember cortisol inc glucose and dec insulin). owners can monitor for attitude of animal, appetite, water and food intake, bwt, urine glucose or ketones (not sensitive but can monitor trends and changes- might help get them to your clinic REMEMBER NEVER CHANGE ANYTHING BASED ON URINE GLUCOSE- MUST DO BG CuRVE).
best at home monitor you can give-- and what you must tell owners NOT to do?glucometers are best option but MUST NOT ALLOW OWNERS TO ADJUST THERAPY. (YOU make the changes based on the curves and clinical signs)
long term monitoringlook for CSs, recheck every 2-4mo, look at fructosamine levels
*most important thing to prevent in pts? why?HYPOglycemia-- bc they can die from this!
changes youll see why hypoglycemiaataxia, depression, ptyalism
possible causes of hypoglycemiaInsulin overdose, Incorrect syringe, Insulin given to anorexic animal/vomiting, Long acting insulin, Cat who requires only Q24h dosing, Aging (metabolism changes), Adrenalectomy, Beta blockers, Remission
tell owner if they suspect hypoglycemia, to...GIVE GLUCOSE. karo syrup is a good option, has lots of sugar. if any doubt, give sugar!
chronic infections are a complication of DM-- why? examples?bc neuts dont work well with lots of glucose. See UTIs, derm, monitor often! culture always! treat aggressively (dead bugs dont mutate)
complications: Surgery: things to consideronly do if necessary. ensure good glycemic control! no food in the AM for sx, so only 1/2 dose insulin AND MAKE SURE THEY ARE FIRST PROCEDURE!! as soon as they are under, start monitoring glucose. give 5% dextrose in the fluids. Can use regular insulin until awake enough to eat then back to SQ. Sxs prolyl happening are spay or cataracts (caused by DM in dogs, can only get rid of with sx)
other complications...Hepatic Lipidosis (dont wanna eat and still have to rx for DM), Iatrogenic Hypoglycemia, Ketoacidosis, Pancreatitis, Neuropathy—cats, dogs less commonly, Persistent clinical signs, Diarrhea, EPI, Gastric paresis, Glomerulonephropathy
If you have a diabetic animal with a prob, first thing you should a bg curve!! then eval for concurrent dzs
explain how to do a BG curveFeed them normally, then admin insulin normally. Then check the BG every 2 or 3 hours for 12-24 hours. (if they are on Q12hr dosing, 12hr usually will suffice, do for 24 if not sure)...if BG is <125, then do Q1 hr measurements (dont want them to get too low!!) If they are showing CSs at night, do the BG curve over night. If once a day insulin, do 24hr BG curve.
what is low point of BG curve called? highest point?ACME= highest point. Nadir= lowest point
adjust insulin DOSE based on..nadir.
adjust insulin FREQUENCY based on...acme
what should the BG nadir be like for dogs? cats? what should the pre-insulin low limit be?DOGS: 120-300. CATS: 70-180. PRE-INSULIN LOW LIMIT: 180!!!! (<-which is the same as the high limit of the nadir range)
what do you think of this BG curve of a dog on Q24hr insulin? this is an ideal BG curve for 24hr dosing. the nadir is in the normal range basically (normal rang for dog is 120-300, cat is 70-180), this is just over 100, and most of the day their BG is staying within the normal range of <200
what should the acme be?remember this is the normal range the glucose should max out to ideally, although as long as they aren't ketotic it should be ok. Dogs should be around 200 or lower, cats should be around 300 or lower (keep in mind stress)
what do you think of this BG curve of a dog on Q24hr insulin? This is NOT idea. The nadir might be in normal range at about 120 (normal range for a dog is 120-300), but the acme is like 400 and shouldnt really be going past 200 that much. Since nadir is normal, dont adjust dose. Instead, you must adjust frequency bc acme is the problem-- go from Q24hr to Q12. AND keep in mind the length of time-- most of the day he is spent too high up on the chart. This dog obv has rapid insulin metabolism.
what do you think of this BG curve of a dog on Q24hr insulin? THiS IS INSULIN RESISTANCE-- giving the insulin didnt change the BG levels much at all. since the nadir is too high, this dog needs MORE insulin. Remember to adjust insulin dose by 10-15% at a time.
*what is insulin resistance? ***why might it happen?insulin resistance is if theyre getting more than 2 units per kg (and normal is a quarter to a half of a unit per kg) and they are still showing CSs, it is def insulin resistance. With this much insulin they should be well regulated-- so why aren't they? EITHER: (1) INCORRECT INSULIN HANDLING/ADMIN or (2) CONCURRENT DZ (could be drugs too, like ear meds have steroids in them which are anti-insulin)
concurrent dzs in dogs or cats which might cause insulin resistance?DOGS: Hyperadrenocorticism (steroids are anti-insulin), Hypothryoidism (thyroid hormone works side by side with insulin to encourage metabolism, so thyroid hormone upregulates insulin receptors-- lack of them dec. Bc remember insulin lets glucose into cells which is part of metabolism, so low metabolism means insulin receptors arent responding well), chronic pancreatitis..... CATS: Hyperthyroidism, Acromegaly (GH is anti insulin), Hyperadrenocorticism (rare in cat)
What is the somogyi effect? If the body has periods of hypoglycemia, you will see a rebound HYPERglycemia-- owners will notice a return of CSs: glucosuria, spot BG measurements will show up hyperglycemic-- this is why you MUST DO A CURVE IF PT IS UNREGULATED. (this is why we adjust dose based on nadir not acme)
what is going on here? This is somoyagi effect-- note that the nadir IS SUPER SUPER LOW so then it rebounds up like crazy. acme is deceptive, but nadir will show you need to actually dec dose

Insulinoma (OPPOSITE OF DM)

Question Answer
who tends to get insulinoma? what age? breeds?Usually FERRETS, dogs, cats. Older. Standard poodles, boxers, terriers
CSs of insulinoma?weak but with good appetite (they want to eat!), seizures (low glucose and elevate epi)
what will chem look like with insulinoma?Fasting hypoglycemia, SEVERELY LOW glucose which is repeatable
you can't just look at blood glucose to know it's insulinoma.. what else must you look at?Insulin levels must be measured concurrently with a BG of <40 mg/dL (so HIGH insulin in face of LOW BG-- and if you draw and BG is low, you need to draw and measure BG and concurrently look at insulin- needs to be from same blood sample)
are there ketones with insulinoma?NO. because formation of ketones is inhibited by insulin!!
how do you image an insulinoma?(1) Radiographs: Ensure thoracic views to evaluate for metastasis (2) Abdominal Ultrasound: Usually very small and not visible-- Metastasis to liver should be evaluated. (can even do a transesophageal US to try to see the panc mass)
R/Os for hypoglycemia(poster child: tiny puppies with not a lot of fat or mass). Cancer cachexia, sepsis, liver dz, insulinoma, hepatoma (remember liver makes insulin like growth factor one which works like insulin, makes BG low), drugs, puppies (esp small breeds- like the poster child), preg with malnutrition
sx tx of insulinoma?excision/debulking (if you find a bump, take that. if not, debulk by taking like half the panc and hope it is in that half often too small to find) liver bx (check for metastasis), post sx risks include: pancreatitis (you poked the pancreas), DM, Cerebral laminar necrosis???? (<--they dont know why)
medical tx of insulinoma?prednisone, Diazoxide, Streptozotocin (<---these two are chemotherapeutics of choice-- if killing panc tho, can risk DM and/or EPI), Dietary management (many small meals) (she said: pred+many small meals is a good option for bad sx candidates)
prog of insulinoma?guarded to poor, Often have metastasized at the time of diagnosis. Treatment is usually palliative


Question Answer
what is a gastrinoma?A gastrinoma is a tumor (G cells) in the pancreas or duodenum that secretes excess of gastrin leading to ulceration in the duodenum, stomach and the small intestine. There is hypersecretion of the HCl acid into the duodenum, which causes the ulcers.
what is Zollinger-Ellison Syndrome?just aka for gastrinoma
who tends to get gastrinomas?older dogs.
what are the 3 routes stomach acid is (1) histamine (2) ACh (3) gastrin (Ach turns on the enterochromaffin cell from a nerve, so does gastrin but by hormone route, and the E cell releases histamine to turn on the parietal cell which secretes the acid)
CSs of gastrinoma?Vomiting +/- hematemesis, diarrhea, melena, anorexia, weight loss
how do you dx gastrinoma?Elevated serum Gastrin levels, Abdominal Ultrasound
how do you tx a gastrinoma?(1) Proton pump inhibitors (2) Sucralfate (3) Surgery (Tumor removal and may need partial gastrectomy- Endoscopy is nice to evaluate for ulcer severity)

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