Blood Glucose Oki Aziz894180

8/14/2019 Blood Glucose Oki Aziz894180

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Oral glucose Tolerance TestOral glucose Tolerance Testand Factors Influencing Bloodand Factors Influencing Blood

Glucose Level.Glucose Level. one By bdulaziz Massoud Alfaydi


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DefinitionDefinition. The glucose tolerance test (GTT)

Consists of drinking (75 to 100 )gramsof glucose solution ..Measuring the blood glucose values

every hour toget a cerve ..A 2 hour GTT is used to diagnosis

diabetes , but a 6 hour test might alsodiagnosis diabetes plus hypoglycemia..Symptoms of hypoglycemia occur after

the 5 th hour..In healthy individual the insuline


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Referance valuesReferance values

Normal /FPG:Adults: 110mg/dl or 6.1 mmol/L.30-minute

Adults 110-170 mg/dl or 6.1-9.4mmol/L.60- minute PG after glucose load :

Adults


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.3- hours PG afterglucose load:

Adults b70-120

mg/dl or 3.9-6.7mmol/L.All four blood

values must bewithin normallimits to beconsidered normal.


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ProcedureProcedure

This is timed test for glucosetolerance . A-2 hourplasma glucose test is done

after glucose load to detectdiabetes in individuals otherthan pregnant women .

The 3- hour test is done forpregnant women .The 4- hourtest evaluates possiblehypoglycemia.

1- Have patiant eat a diet with


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Ensure that the following drugsare discontinued 3 dayes beforethe test because they mayinfluence test results:

a) Hormones , oralcontraceptives , steroids.

b)Salicylates, anti inflammatory

drugs.C)Diuretic agentsd) Hypoglycemic agents.

.e)Antihypertensive drugs


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F)Anti convulsants .3-Insuline and oral hypoglycemics

should be with held until the testcompleted .

4- Record the patient s weighta)Pediatric doses of glucose are

based on body weight. Calculated

as 1.75g/kg not to exceed a totalof 75g.b)Pregnant women 100g glucose.C) Non pregnant adults 75g

glucose.


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5-A 5ml sample of venous blood isdrawn. The patient should fast 12to 16 hours before testing .

6-Bbood samples are obtained 30menutes , 1 hr, 2hrs, 3hrs afterglucose ingestion.

7- Specimens taken 4 hrs afteringestion are significants fordetecting hypoglycemia .

8-Tolerance tests can also be

performed for pentose ,lactose-


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a) Persistent fastinghyperglycemia >140mg/dl or>7.8mmol/l.

b) persistent fasting normalplasma glucose .

c)Patient with overt diabetes

mellitus.d)Persistent 2-hour plasmaglucose >200mg/dl or>11.1mmol/l.


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Interfering factorsInterfering factors

1- Smoking increases glucoselevels.

2-Altered diets (weight reduction)

before testing can diminishcarbohydrate tolerance andsuggest ,false diabetes.

Glucose levels normally tend toincrease with aging.3-Prolonged oral contraceptive

use causes significantly higherlucose levels in the second


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5-Infections disease illnesses andoperative procedures affectglucose tolerance.

6- Certain drugs impair glucosetolerance levels .a) Insulin .b) Oral hypoglycemics.c)Large doses of salicylates , anti-

inflammatoriesd) Thiazide diuretics.e) Oral contraceptives.


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1a. Normal Minimum curve1a. Normal Minimum curveaccording to Seale Harrisaccording to Seale Harris

Time [hours] 0 0.5 1 2 3 4 5 6

Blood glucose [mg/dl] 80 90 105 90 80 80 80 80


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1b. Normal Maximum1b. Normal Maximumcurvecurve

Time [hours] 0 0.5 1 2 3 4 5 6



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..diabetesdiabetesTime [hours] 0 0.5 1 2 3 4 5 6

Blood glucose[mg/dl] 115 145 180 160 120 130 130 130

h3 C i h


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3. Curve with severe3. Curve with severediabetesdiabetesTime [hours] 0 0.5 1 2 3 4 5 6


b d4 Di b d


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4. Diabetes and4. Diabetes andhypoglycemiahypoglycemia

Time [hours] 0 0.5 1 2 3 4 5 6



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5. Continuous low values5. Continuous low values Time [hours] 0 0.5 1 2 3 4 5 6



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6. Pre-hypoglycemia6. Pre-hypoglycemia Time [hours] 0 0.5 1 2 3 4 5 6



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7. Mild hypoglycemia7. Mild hypoglycemiaTime [hours] 0 0.5 1 2 3 4 5 6



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8. Severe hypoglycemia I8. Severe hypoglycemia ITime [hours] 0 0.5 1 2 3 4 5 6



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10. Flat curve10. Flat curve Time [hours] 0 0.5 1 2 3 4 5 6



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f) Corticosteroids.g) Estrogens.h) Heparin.

i) Nicotinic acid . j) Phenothiazines.k) Lithium .l) Metryrapone(metopirone).


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HOMEOSTASIS NORMALHOMEOSTASIS NORMAL

3 Mechanisms:

1.Metabolic2.Hormonal3.Renal


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MetabolicMetabolic.Dietary-Primary

source of all bodycomponents

Glycogen-Initial-liver(92%), later-

muscle(8%),sufficient for 18 hrsGluconeogenesis:Non-cabohydrates Glucogenic amino acids all except ,lys,

leu TG Glycerol DHAP Odd chain FA-PropionicAcid

Succinyl CoA Lactate Pyruvate


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HormonalHormonal

Insulin- cell of Langerhans favoursuptake into cell

Glucagon,

epinephrine,glucocorticoids,GH,thyroxin-antagonists to insulin,favoursexcessive glycogenolysis andrelease of more glucose in blood

Cooperative action of both types of hormones help maintaining theblood glucose


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RenalRenal

Rates of Glomerularfiltration and Tubular absorption maintain bloodglucose

Kidney threshold for glucose-180 mg%, more than this spillover in urine glycosuria

TMG-375 mg/min,more accurate indexthan kidney threshold


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ABNORMALABNORMAL

HYPERGLYCEMIAHYPOGLYCEMIA


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HYPERGLYCEMIA:HYPERGLYCEMIA:

DIABETES:10 % population worldwide affected, 2

%>50 y


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:: Iry (Known causes)Iry (Known causes)

I.IDDM- Insulin deficiencyI.IDDM- Insulin deficiencyAutoimmune -Immunity mediated(Antibodies to

insulin 50%,antibodies to islet cell cytoplasmicproteins 80%), idiopathic( damage of cell of islet of Langerhans or viral infection)

II.NIDDM- Normal insulin but unavailable(insulinresistance)-Obese(60%),non-obese(40%)(antibodies),MODY (maturity onset diebetes of young)(Glucokinase ,gene mutated-KT insulin )

III.Prone -i)Gestation-occurs 15%nondiabetes diabetes, Childrisk mortality ,BWt ,ii)IFG, iii)IGT


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IIry (Unknown causes)IIry (Unknown causes)

Pancreatic diseases-pancreatitis,cystic fibrosis

Endocrinopathies-cushing

syndrome,thyrotoxicosis,acromegalyDrug induced-steroids, blockers


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GLYCOSURIAGLYCOSURIA

GFR-NC,KT & TMG A. HYPERGLYCEMIC:

Alimentary-IFG

Emotional-sympathetic and splanicnerve excitation

Endocrinal

Experimental-alloxan


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GLYCOSURIAGLYCOSURIA

B.RENAL:HereditaryAcquired

Threshold ( 180 mg%) Tubular reabsorption Experimental-phloridzine


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II.HYPOGLYCEMIAII.HYPOGLYCEMIA

Risk-50 mg%,fatal < 30 mg%Insulin

Thyroid Liver diseasesSevere exerciseGlycogen storage diseasesAlcohol ingestion.


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DIEBETES STATUSDIEBETES STATUS

MONITORINGA.Conventional:

Glucose-Blood (GOD-POD)-Urine

Benedict reagent

G Y O R0.5% 1% 1.5% 2->2%

GTT: 1.Lab-Oral GTT (OGTT)

2.Clinic-Post-prandial (meal)


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B. Modern investigationsB. Modern investigations

1.Glycated Hb(HbA1c) (Normal 4-8%)-1%30% risk (life span 120D)

2.Glycated albumin-fructosamine(life span 20D)

3.Lipid profile4.Microalbuminuria- >300 mg%/D excretion5.Ketone bodies (Bl.0-2 mg % 125 mg

%,urine 20-60 mg% 5000 mg% /D )


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Factors affecting GTTFactors affecting GTT

Concerned with the blood glucoseregulation

1.Metabolic-diet-thiamine

-starvation-excretion-liver diseases, infection

2.Hormones-insulin-antagonists

epinephrine,glucagon,glucocorticoids,

GH,thyroxin.


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GTTGTT


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MANAGEMENT OFMANAGEMENT OFDIEBETESDIEBETES

Organs involved-side effects-complications,acute,chronic-multipleorgans.


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CLINICAL PRESENTATION INCLINICAL PRESENTATION INDMDM

Cardinal Symptoms:Complications1.Poly-urea-Urine (wt.loss)

-dypsea-thirst-water intake -phagia-Food intake

2.Chronic skin infection-Boils-Celluloitis-Absesses

3.Plaques-CVD:CHD+CADMyocardial infarction4.Retinopathy5.Nephropathy6.Fatty liver


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7.Ketone bodies8.altered lipid profile


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Drug therapy for DKADrug therapy for DKAInsulin therapy: lower BG by 75-

150mg/dl/hr1. Regular insulin IV bolus dose of .1u/kg

followed by IV drip of .1u/kg/hr.2. SQ insulin when client can eat and ketosis

has ended.Electrolyte replacement

1. Potassium2. Bicarbonate


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Treatment for DKATreatment for DKA

Frequent assessment of client: LOC,V/S, blood glucose levels, fluid andelectrolyte status

Correct fluid volume deficit1. 1 liter of hypertonic solution (D51/2NS)

over 8 to 12 hrs.2. 1 liter of isotonic saline over 1 hour3. 1 liter of hypotonic saline over 6 to 8 hrs


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Management ofManag

ement of


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Management of Manag ement of HypoglycemiaHypoglycemia

Hypoglycemic protocol1. Mild hypoglycemia (BG < 60 and

symptomatic)- 10 to 15g of carbohydrate- Recheck BG in 15minutes

2.Moderate (BG < 40 and symptomatic)-15 to 30g of rapidly absorbed CHO

3. Severe (BG < 20 and unable to swallow)- 1mg of glucagon IM/SQ or

amp of D50 IVP

HbAHbA Predicts CHD in TypePredicts CHD in Type


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0

5

10

1520

25

0

5

10

1520

25

HD mortali ty(%) .ncidence in 3 5

years

l l CHD events(%) .ncidence in 3 5

years

HbA1c HbA1c

Low< %

Middle- . %7 9

High> .9

%

Low< %

Middle- . %7 9

High> .9

%

HbAHbA 1c1c Predicts CHD in TypePredicts CHD in Type22


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ADA Treatment GoalsADA Treatment Goals

Hgb A1C maintained at 7% or below. Premeal blood glucose level 70 to

110mg/dl

Blood glucose at bedtime 100-140mg/Dl


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Values for HbAValues for HbA 1c1c

Non-diabetic


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Hemoglobin AHemoglobin A 1c1c

A blood testthat showsglucose levelsfor the past 3months

No preparationneeded i.e.fasting, etc.

H b A 1 cH b A 1 c


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Checking Blood GlucoseChecking Blood Glucose

CBGs

AccuChecksGlucometerGlucoscan


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Lab Assessment for AllLab Assessment for All

Diabetic ClientsDiabetic ClientsBlood tests

1. Fasting Blood GlucoseTest (Cavenaugh pg. 105)

2. Blood GlucoseMonitor Systems2. Oral Glucose

Tolerance Test(Cavenaugh pg. 109)

3. Glycosylated Hemoglobin

Assays (Cavenaugh pg. 112)4. Glycosylated Serum

Proteins and Albumin(Cavenaugh pg. 114)


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Type 2 DiabetesTyp e 2 Diabetes

80% are obese10% non-obese10% unstable:may look morelike a Type 1Diabetic

Type 2 DiabetesType 2 Diabetes


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Type 2 Diabetes Type 2 DiabetesSigns and SymptomsSig ns and Symptoms

HyperglycemiaPolyuriaPolydipsiaBlurred visionFatigueParesthesiasSkin infections


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Type 2 DiabetesType 2 DiabetesEtiologyEtiology

There isabnormallyhigh level of glucose

Pancreas does produce insulin

Body resists theinsulinseffects


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DIABETES COMPARISONDIABETES COMPARISONTYPE 1TYPE 1 TYPE 2TYPE 2

AutoimmuneProcess: Betacellsdestroyed Insulin deficiency

Has no insulin

IdiopathicGeneticpredisposition

< Age 30

Insulinresistance hassome insulin

Obesity is risk factorPhysical inactivityGenetic

predispositionAdult onset

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Blood Glucose Oki Aziz894180