Endocrine
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Adrenal Insufficiency
- When to suspect: chronic steroid use (almost any steroid dose for several weeks, exact amount varies by source), septic shock with elevated pressor use, known history of adrenal insufficiency, prior adrenal surgery, autoimmune conditions plus hypotension, known pituitary/hypothalamus disease or manipulation
- If infected and/or borderline hypotensive consider stress dose steroids for 48 hours (hydrocortisone 50mg IV every 6 hours or 100mg IV every 8 hours)
- Suspect if: hyperglycemia > 250 (SGLT2 inhibitors like Invokana/canagliflozin can have euglycemic DKA), urine or serum ketones, ABG or VBG pH < 7.30, bicarbonate < 18, anion gap > 12 though no longer required, beta hydroxybutyrate (BHB) > 2-4, can have nausea or abdominal pain
- Triggers: medication or dietary indiscretion, new diagnosis of diabetes, infection, MI
- Begin aggressive fluid resuscitation and potassium repletion (can replete up to about 5.0mEq/L)
- Insulin REGULAR IV bolus (usually not subcutaneous aspart unless in specific situations): 0.1 units/kg bolus and 0.1 units/kg/hr. Nursing will adjust insulin drip per protocol. Start D5 0.45% infusion when glucose below 250 mg/dL to prevent hypoglycemia
- Hold all oral diabetes medication or long acting injectable antihyperglycemic medications (doesn’t include insulin) while in the hospital due to frequent NPO needs and ability to closely monitor
- Goal glucoses inpatient 140-180mg/dL
- Rough guide to sliding scale: if no or one oral diabetes medication at home then low sliding scale, if on several oral diabetes medications or low doses of insulin then medium sliding scale, if on medium to high doses of insulin at home then high sliding scale
- If using sliding scale to estimate insulin needed in hospital: calculate number of units of insulin needed in last 24hrs and either make 100% basal Lantus or make 60% prandial aspart (split over 3 meals) and 40% basal Lantus (at night)
- If going to be NPO the next day: hold all prandial insulin (can give sliding scale) and reduce long acting insulin (Lantus) to 2/3 of original amount
- For patients who are on tube feeds or TPN via PICC line, consider fingersticks every 6 hours rather than with meals