When should insulin be stopped in HHS?
Stop the insulin when glucose approaches ~300 mg/dL Dropping the glucose below 180-270 mg/dL (10-15 mM) may increase the risk of cerebral edema. In HHS (without ketoacidosis), there is no mandate to overlap the insulin infusion with basal insulin.
Which antidiabetic drugs are contraindicated in patients with hyperglycemic Index (HI)?
Older antidiabetic drugs such as metformin and SUs have been least investigated in HI patients; hence, their use is contraindicated in patients with moderate to severe HI. Such patients may be at higher risk of lactic acidosis (with metformin) and hypoglycemia (with SUs).
When does HHS recommend abrupt dose reduction or discontinuation of long-term opioids?
• Unless there are indications of a life-threatening issue, such as warning signs of impending overdose, HHS does not recommend abrupt opioid dose reduction or discontinuation. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics
Can a diabetic patient be discharged from the hospital without HHS?
A patient with poorly controlled diabetes who just ate a large amount of carbohydrates could satisfy the criteria above without truly having HHS. For example, some patients with initial glucose values in the 600-800 mg/dL range can be safely discharged home from the emergency department (figure below).
When do you stop IV insulin in HHS?
dose the insulin infusion conservativelyDon't use a bolus.The starting dose is 0.05 U/kg/hr (half of the initial dose used in DKA).The target should be to reduce the glucose by ~40-80 mg/dL per hour (2.2-4.4 mM). ... Stop the insulin when glucose approaches ~300 mg/dL.More items...•
Why do we stop metformin in the hospital?
The FDA also added a warning against the use of metformin in patients with sepsis or in patients older than 80 years who have abnormal creatinine clearance. Acute kidney injury, a common inpatient condition, occurs in 20% of hospitalized patients and more than 50% of inten- sive care patients.
When should you discontinue DKA pathway?
DKA is resolved when 1) plasma glucose is <200–250 mg/dL; 2) serum bicarbonate concentration is ≥15 mEq/L; 3) venous blood pH is >7.3; and 4) anion gap is ≤12. In general, resolution of hyperglycemia, normalization of bicarbonate level, and closure of anion gap is sufficient to stop insulin infusion.
When should antidiabetics be stopped before surgery?
For patients controlled on oral agents, discontinue drugs 1 day before surgery. Discontinue biguanides (metformin) on the day of surgery because alterations in renal function arising intraoperatively may potentiate the risk of the patient developing lactic acidosis.
Do you need to stop metformin in a hospitalized patient with diabetes?
Bottom line. Patients who were taking metformin appropriately prior to hospitalization can safely continue metformin during their hospitalization if they do not have medical risk factors for developing lactic acidosis.
How does metformin cause lactic acidosis?
The pathophysiology of lactic acidosis from metformin is likely due to inhibition of gluconeogenesis by blocking pyruvate carboxylase, the first step of gluconeogenesis, which converts pyruvate to oxaloacetate. Blocking this enzyme leads to accumulation of lactic acid.
How is hyperosmolar hyperglycemic state treated?
Treatment typically includes:Fluids given through a vein (intravenously) to treat dehydration.Insulin given through a vein (intravenously) to lower your blood sugar levels.Potassium and sometimes sodium phosphate replacement given through a vein (intravenously) to help your cells function correctly.
Why do you give dextrose in DKA?
Why is IV dextrose given to patients with DKA? When the serum glucose reaches 200 mg/dL in a patient with diabetic ketoacidosis (DKA), IV dextrose is added to avoid the development of cerebral edema. In addition, the rate of insulin infusion may need to be slowed down to between 0.02 and 0.05 units/kg/hr.
Why do you give potassium in DKA?
Replacement of potassium in intravenous fluids is the standard of care in treatment of DKA to prevent the potential consequences of hypokalemia including cardiac arrhythmias and respiratory failure.
Why are oral hypoglycemics stopped before surgery?
Patients with type 2 diabetes mellitus receiving oral hypoglycemic drugs (OHDs) are usually instructed to stop them before surgery. We hypothesize that continuing OHD preoperatively should result in lower perioperative blood glucose (BG) levels.
Why do you have to stop taking metformin before surgery?
If you take metformin, talk to your provider about stopping it. Sometimes, it should be stopped 48 hours before and 48 hours after surgery to decrease the risk of a problem called lactic acidosis.
Why do you stop insulin before surgery?
Managing your blood glucose before surgery helps to reduce your risk of infection and other problems after surgery.
What are the goals of ADHF?
The overall goals of therapy in ADHF include: identifying precipitating factors (Table 22), relieving symptoms, directly improving short- and long-term outcomes, and initiation and optimization of long-term therapies.
How many people will have heart failure by 2030?
The American Heart Association is predicting that more than eight million Americans will have heart failure by 2030 and that the total direct costs associated with the disease will rise from $21 billion in 2012 to $70 billion in 2030. The increase in the prevalence and cost of HF is primarily the result of shifting demographics and a growing population. Although many large, randomized, controlled clinical trials have been conducted in patients with chronic heart failure, it was not until recently that a growing number of studies began to address the management of ADHF. It is the intent of this review to update the clinician regarding the evaluation and optimal management of ADHF.
What is ADHF in medical terms?
Acute decompensated heart failure (ADHF) is the rapid onset of, or change in, symptoms and signs of HF. It can be a life-threatening condition that requires immediate medical attention and usually leads to hospitalization. Acute decompensated heart failure continues to rise in prevalence and is associated with substantial mortality and morbidity. In the US, over 1 million patients are hospitalized annually with HF as a primary diagnosis with an additional 3 million hospitalizations with HF listed as a secondary or tertiary diagnosis [1]. Heart failure is the leading cause of hospitalization in patients older than 65 years of age. The readmission rate is as high as 35% at 60 days [1]. The majority of the enormous cost (80%) of HF care is attributable to hospitalization [2].
Is ADHF a controlled trial?
Although many large, randomized, controlled clinical trials have been conducted in patients with chronic HF, it was not until recently that a growing number of studies began to address ADHF management. This article will review the evaluation and optimal management of ADHF and discuss the results of recent trials. It is important to note that the majority enrolled in ADHF trials are largely patients with HF due to reduced ejection fraction, and thus, this population is the primary focus of this review.
Is invasive hemodynamic monitoring necessary for ADHF?
Routine use of invasive hemodynamic monitoring in patients with ADHF does not impact survival and is not routinely recommended [12]. However, invasive monitoring should be considered in patients who are refractory to initial therapy, those in whom volume status is unclear, or who have hypotension or worsening renal function despite therapy. In addition, documentation of an adequate hemodynamic response to inotropic therapy is often necessary prior to initiating chronic outpatient therapy [13].
When to delay insulin?
It's generally advisable to delay insulin until the glucose has already been reduced by dilution with isotonic crystalloid (volu me resuscitation step above).
What is the most important aspect of treating DKA?
Perhaps the most important aspect of treating DKA or HHS is ensuring that no underlying process is missed (e.g., sepsis, pancreatitis, myocardial infarction, CVA). HHS carries a high mortality (often quoted ~15%) – but this is largely due to comorbid problems and triggers, rather than the HHS itself. ( 31142480)
How much does osmolality decrease?
A reasonable target might be to reduce the serum osmolality by ~20 mOsm/L per day (possibly faster in patients with altered mental status). However, if the osmolality decreases faster than intended, it will probably be safe.
How long does it take for HHS to develop?
HHS is a deranged state which develops gradually over days to weeks. However, these patients generally adapt to their new state and often tolerate it relatively well. As a general rule of thumb, if an abnormal state develops gradually then it may be treated gradually.
How much DKA is 0.05?
The starting dose is 0.05 U/kg/hr (half of the initial dose used in DKA).
Why do patients fail to compensate adequately for water loss?
Patients fail to compensate adequately for water loss by increasing oral water intake (e.g., due to baseline debility, bed-bound status, or a relatively insensitive central drive to maintain normal tonicity). Over a period of several days, uncontrolled water loss leads to a hypertonic state.
Is HHS difficult to diagnose?
HHS generally isn't difficult to diagnose, given that essentially all ill patients will receive a glucose measurement upon evaluation in the emergency department.#N#Profound hyperglycemia should always raise a question of whether the patient has HHS.
Why are serum ketones not present in patients with type 2 diabetes?
Serum ketones are not present because the amounts of insulin present in most patients with type 2 diabetes are adequate to suppress ketogenesis.
Why are serum ketones not present in diabetics?
Serum ketones are not present because the amounts of insulin present in most patients with type 2 diabetes are adequate to suppress ketogenesis. Because symptoms of acidosis are not present, most patients endure a significantly longer period of osmotic dehydration before presentation, and thus plasma glucose ( > 600 mg/dL [ > 33.3 mmol/L]) and osmolality ( > 320 mOsm/L) are typically much higher than in diabetic ketoacidosis.
What are the complications of hyperglycemic state?
Complications include coma, seizures, and death. (See also Diabetes Mellitus and Complications of Diabetes Mellitus .) Hyperosmolar hyperglycemic state (previously referred to as hyperglycemic hyperosmolar nonketotic coma [HHNK] and nonketotic hyperosmolar syndrome [NKHS]) is a complication of type 2 diabetes mellitus and has an estimated mortality ...
What is the HHS?
Hyperosmolar Hyperglycemic State (HHS) Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 diabetes, often in the setting of physiologic stress.
When to add dextrose?
Dextrose should be added once the glucose level reaches 250 to 300 mg/dL (13.9 to 16.7 mmol/L). The rate of infusion of IV fluids should be adjusted depending on blood pressure, cardiac status, and the balance between fluid input and output.
Is osmolality higher in diabetics?
Because symptoms of acidosis are not present, most patients endure a significantly longer period of osmotic dehydration before presentation, and thus plasma glucose ( > 600 mg/dL [ > 33.3 mmol/L]) and osmolality ( > 320 mOsm/L) are typically much higher than in diabetic ketoacidosis.
Does insulin help prevent ketoacidosis?
Patients have adequate insulin present to prevent ketoacidosis.
How long does it take for lofexidine to taper off?
tapering from long-term opioid treatment for pain.7Lofexidine has an FDA-approved indication for use up to 14 days for “mitigation of opioid withdrawal symptoms to facilitate abrupt opioid discontinuation in adults.”
What are the benefits of opioid reduction?
pain, function, and quality of life improved after opioid dose reduction.10
What is the DSM-5 for opioid use disorder?
#TAB#If patients experience unanticipated challenges to tapering, such as inability to make progress despite intention to taper or opioid-related harm, assess for opioid use disorder using DSM-5 criteria.2 If patients meet criteria for opioid use disorder (especially if moderate or severe), offer or arrange medication-assisted treatment.2,3
How long does it take for a psychotic disorder to stop?
Generally, they should be reduced and stopped slowly, ideally over weeks to months. Relapse of psychosis and exacerbation occur in most patients with psychotic disorders, occasionally with drastic consequences. Sometimes this occurs many months after stopping antipsychotics.
Why is it important to switch from one antipsychotic to another?
Switching from one antipsychotic to another is frequently indicated due to an inadequate treatment response or unacceptable adverse effects. It should be carried out cautiously and under close observation
What antipsychotics do psychiatrists use?
Psychiatrists also use some antipsychotics such as olanzapine, quetiapine and risperidone for off-label indications. An example would be adjunctive initial treatment of severe major depression when rapid relief of agitation, insomnia and suicidality is needed while waiting for antidepressants to take effect. As a consequence, GPs are seeing a broad spectrum of patients (not merely those with schizophrenia) who have been started on antipsychotics, often in combination with other psychotropic drugs. It has been common practice to continue these antipsychotics long term, especially when treatment of an acute episode has been reasonably successful. However, long-term antipsychotic use can have serious consequences including tardive dyskinesia, weight gain, metabolic syndrome, diabetes and cardiovascular complications.3
What is the switch to antipsychotics based on?
Switching antipsychotics based on risk of adverse effects
Why should antipsychotics be reviewed?
Antipsychotics for behavioural disturbance associated with dementia and other brain diseases should be reviewed and deprescribing should be considered due to the serious adverse effects and lack of evidence for long-term use .7
Is stopping antipsychotics necessary?
Stopping antipsychotic drug therapy is feasible and appropriate in a number of clinical circumstances. For patients who require long-term treatment, switching to another antipsychotic may be needed if their response to treatment has been inadequate, or unacceptable adverse effects have occurred.
Do antipsychotics need to be long term?
While antipsychotics are often needed long term, there are circumstances when clinicians, patients and families should reconsider the benefits versus the harms of continuing treatment
What is controlled discontinuation?
Controlled discontinuation trials are really just treatment initiation trials in reverse. First, identify reliable observers; usually parents, a teacher, and of course your child. Then, using standard rating scales, have all observers rate target symptoms and possible side effects, at baseline on the current dose of medication.
What is discontinuation trial?
A discontinuation trial to see if medication is causing a side effect could yield one of four possible results:
Is ADHD medication better than nothing?
In retrospect, the medication wasn’t perfect but it was still substantially better than nothing. Here, if there were no side effects, you and your prescriber should consider increasing the dose. • Possible remission is when ADHD symptoms were well-controlled on medication but do not come back off medication.
Does ADHD change over time?
Also remember, ADHD changes. Over the years, predominant hyperactivity and impulsivity symptoms often transform into more subtle distractibility and executive dysfunction. Children learn compensatory skills. Just because discontinuation caused more obvious symptoms in the past does not mean that your child has completely outgrown the disorder. The important decision to stop medication should be made carefully, after data is collected in a more deliberate and reliable manner.
Is discontinuation the only change?
In real life, it’s almost impossible to control all the variables. Medication discontinuation is never the one and only change.
Does discontinuing medication make it worse?
Sometimes discontinuation makes a presumed side effect worse instead of better. For example, on medication, many children with ADHD actually have less trouble with eating, sleeping, and mood, especially if these problems were partially driven by hyperactivity, impulsivity, or distractibility.
Do people do discontinuation trials?
Unintentionally, people do discontinuation trials all the time. A dose is forgotten. A capsule is found between the sofa cushions. A bottle isn’t packed. A prescription isn’t refilled. The family dog suddenly stops chasing squirrels! (Just kidding.)