Diabetic Emergencies Flashcards
Consequences of diabetic emergencies
Blindness
Renal failure
Amputation
Heart disease (basically inevitable)
Stroke
What does being Hyperglycemic for long periods of time increase risks of? why?
Infection
MI
PE
CVA
DVT
Bodily functions that happen when someone is Hyperglycemic for long periods of time
Clotting
Vasoconstriction
Impaired gastric motility
Decreased respiratory muscle function
*Target goals of blood sugar for patient with hyperglycemia in ICU
Initially: less than or equal to 180
Then *140-180
Why aren’t targets of less than or equal to 110 recommended?
May be associated with increased mortality
What is glucose metabolism regulated by?
Regulated by the liver
How does the liver regulate glucose metabolism?
Liver stores and synthesizes glucose (stored as glycogen)
Liver releases glucose when BS decreases
Liver stores glucose when BS increases
How is glucose stored?
In the liver as glycogen
In skeletal muscle as glycogen
In fat cells as triglycerides
What does insulin stimulate?
Glucose uptake by cells
Synthesis of glycogen
Synthesis off protein and amino acids
Transport of amino acids and fatty acids into cells
Conversion of fatty acids to triglycerides
What does insulin inhibit?
Glucose production (by glycogenolysis and glyconeogenesis)
Lipolysis
Protein catabolism
What is glycogenolysis?
Breakdown of glycogen into glucose to be used
What is gluconeogenesis?
Production of glucose from proteins/fat
What is the body’s physiologic response to insufficient insulin?
Decreased glycogenesis (glucose stays in bloodstream)
Increased glycogenolysis (but not enough insulin to actually use, so it stays in blood)
Increased gluconeogenesis
Decreased glycolysis
Increased Lipolysis
What is glycolysis?
Breakdown of glucose to CO2 and H2O
What is Lipolysis?
Breakdown of fats to ketones, an alternative energy source
What are the 5 counterregulatory hormones?
Glucagon
Epinephrine
Cortisol
Norepinephrine
Growth hormone
*What do the counterregulatory hormones do?
*Increase blood glucose
What causes a Hyperglycemic crisis (DKA or HHS)?
Result from reduction in net effect of circulating insulin
Coupled with simultaneous elevation of counter-regulatory hormones
Results in hepatic and renal glucose production and decreased use of glucose in peripheral tissues
*Common factors leading to DKA/HHS
Omission of adequate treatment of DM
New-onset DM
Infection
Pre-existing illness
Acute illness
Stress
Other endocrine disorders
High-calorie parenteral/enteral nutrition
Description of DKA
Acute complication of DM
Associated with insulin deficiency, coupled with simultaneous increase in counterregulatory hormones
*Results in hyperglycemia, dehydration, electrolyte depletion, and ketones
*Develops quickly
S/S of DKA
Hyperglycemia
Dehydration
Electrolyte depletion
Ketosis
Contributing factors of DKA
Insulin pump malfunction
Insulin pump infusion set/site issues
Increased insulin need
What could be the causes of insulin pump infusion set/site issues?
Infection
Disconnection
Catheter kink/migration
What could cause increased insulin need?
Insulin resistance due to:
Pregnancy
Puberty
Before menstruation
Clinical manifestations of DKA
Classic S/S: Polyuria, polydipsia, polyphagia, hot dry skin
Cardiovascular: Dehydration, electrolyte imbalances, Tachycardia, hypotension, Weak, thready pulse
GI: Anorexia, nausea, vomiting, abdominal pain, weight loss (r/t decreased blood volume from loss of fluid)
Neuro: Lethargy, fatigue, altered LOC
Respiratory: Fruity breath, Kussmaul respirations
*Blood glucose measurement for DKA
> 250mg/dL (but often much higher: average = 675)
Ketone findings for DKA
Positive serum and urine ketones
PH for DKA
<7.30
*HCO3 for DKA
<15 mEq/L
Sodium for DKA
May be normal, low, or high
*Potassium for DKA
May initially be normal, then high, then low (low b/c insulin also causes potassium to go into cells)
*regardless of what serum potassium says, there is always a total body potassium defecit
BUN and creatinine for DKA
BUN >20mg/dL
Cr >1.5 mg/dL
Serum osmolality for DKA
Avg 330 mOsmkg (*measures concentration: higher = more dehydrated)
Order of interventions to manage DKA
Correct volume depletion
Correct hyperglycemia
Correct electrolyte imbalances
*What type of insulin is used to correct hyperglycemia emergencies?
Short acting aka regular insulin
Description of HHS
Hyperosmolar, hyperglycemic state resulting from inadequate insulin secretion *without significant ketosis
Higher than average BG and higher osmolality
*Insidious onset
May be more severe than DKA
Patients HHS are more common in
Type 2 DM and elderly
Possible causes of HHS
*Dehydration (diuretics & not replacing fluids, decreased thirst)
*Stressed induced (MI, CVA, infection)
Enteral/parenteral nutrition
MI, CVA
Glucocorticoids (for long periods)
Other drugs
Clinical manifestations of HHS
Dry skin & mucous membranes
Extreme thirst (OA may not)
Extreme dehydration (Hypotensive, tachycardia)
Neuro: Generalized focal seizures, Reversible hemiparesis, Confusion, Possible coma
*BG for HHS
> 1000 mg/dL
*Osmolality for HHS
> 350 mOsm/L
pH for HHS
> 7.30
HCO3 for HHS
> 15 mEq/L
Ketones for HHS
Negative serum and urine ketones
Sodium for HHS
Varies related to hydration
Potassium for HHS
Varies related to hydration
BUN and creatinine for HHS
Elevated
Goal for HHS management
To complete rehydration and normalize BG in 24-48 hours
*Guidelines to treat HHS and DKA
*Replace half of estimated fluid deficit in 8 hours
*Replace remainder in next 16 hours
Which patients do we need to be even more careful with when replacing fluids?
Patients prone to pulmonary edema, such as pts with renal failure or heart failure
Older adults
Need more frequent monitoring during first hour
*Exact guidelines for treating patients with fluid volume deficit related to osmotic diuresis secondary to hyperglycemia
(Which type of fluid to use when)
1 - Infuse NS 1 liter over first hour (999 mL/hr) as long as pt can tolerate
2 - Change to .45% NS when Na is normal or increased
3 - When BG reaches about 200 mg/dL, D5&1/2NS to prevent hypoglycemia
When treating FVD in hyperglycemia, what should fluids do you give after the NS for the first hour?
- Then 10-15 mL/kg/hr if not shocky (monitor VS, LOC, CVP, PAP, I&O qh)
- If shocky, 20 mL/kg/hr. Once stable, 7.5 mL/kg/hr
- Monitor for overload (crackles, decreased LOC, increased BP)
How do you determine if a patient is not tolerating fluids?
S/S
Regain then lose consciousness
Hearing crackles
Bounding pulses
New onset of high hypertension
Which electrolytes may need to be replaced after managing FVD in hyperglycemic patients?
K
Phos
Mg
Cl
*Symptoms of hypokalemia
Muscle weakness
Cramps
Abdominal distention
Hypotension
Weak pulses
Broad flat T waves
U wave visible
PVB’s (heart muscle not right, ventricles over compensating)
When does insulin and monitoring of ventricles begin?
After:
1 - 1st liter of IVF
2 - K > 3.3 mEq/L (20-30 mEq of K added to IVF)
3 - Pt is producing urine
*What is the goal for reducing blood glucose?
Reduce by 50-75 mg/dL/hr
After treating a DKA patient for FVD, how do you begin treatment with insulin? What is the goal?
1st: loading dose of regular insulin (0.1 u/kg of ideal body weight)
2nd: regular insulin infusion at 0.1 u/kg/h until pH>7.3 and HCO3 >15 mEq/L
Monitor BG hourly
Pt usually NPO
For a DKA patient, when pH and HCO3 goals are reached, what should you decrease insulin by? And what is the target?
3rd: decrease by 0.05 u/kg/hr with target of 100-150 mg/dL until acidosis is resolved
Monitor BG hourly
Pt usually NPO
Next steps after acidosis is resolved in a patient with DKA and glucose goal is reached:
SC insulin 1-2 hrs prior to discontinuation of infusion, when BG < or = to 200 mg/dL and 2 of the following are met:
Venous pH >7.3
HCO3 > 15 mEq/L
Anion gap > or + 12 mEq/L
Once glucose goal is reached and pt’s infusion is ready to be discontinued, how often should BG be monitored?
Every 6-8 hours
When should acidosis be treated with bicarb?
If HCO3 is < 7 or pH is <7
For a HHS patient, when pH and HCO3 goals are reached, what should you decrease insulin by? And what is the target?
Decrease by 0.2-0.5 u/kg/hr when BG 300 mg/dL
With target 200-300 mg/dL
When should HHS patients be transitioned to SC insulin?
When mental status improves
Why are the guidelines different for decreasing insulin and goal BS different between DKA and HHS patients?
Blood sugar is usually higher in HHS patients and these patients are usually more dehydrated
So their symptoms will be fixed faster because of this
Education for patient and family after hyperglycemic crisis:
Education to prevent future episodes:
Hydration
Reporting illness
Reporting BS >250
Reporting inability to keep food or fluids down
Sick day rules
Monitoring A1C levels
*Description of hypoglycemia
Acute condition in which relative or absolute *excess of insulin results in *BG < 70 mg/dL
Causes of hypoglycemia
Too much exogenous insulin
Inappropriate site rotation
Absorption variability
Gastroparesis (delayed emptying)
Inadequate intake
Increased energy requirements
Impaired counterregulation (don’t have those 5 hormones)
Hypoglycemic unawareness
5 hormones involved in hypoglycemia
Glucagon
Epinephrine
Cortisol
Norepinephrine
Growth hormone
(Glucose usage is inhibited in peripheral tissues by epi, cortisol, GH)
Symptoms of mild hypoglycemia
And BG level
Patient completely alert
Pallor
Diaphoresis
Tachycardia
Palpitations
Hunger or shakiness
BG < 51-70
Patient is able to drink
Treatment of mild hypoglycemia
10-15g of glucose (carbohydrate) by mouth
Symptoms of moderate hypoglycemia
And BG level
Patient is conscious, cooperative, and able to swallow safely
Difficulty concentrating
Confusion
Slurred speech
Extreme fatigue
BG < 55 mg/dL
Patient is able to drink
Treatment for moderate hypoglycemia
20-30 g of glucose (carbohydrate) by mouth
Symptoms of severe hypoglycemia
And BG level
Patient is uncooperative or unconscious
BG < 54 mg/dL or patient is unable to drink
Treatment for severe hypoglycemia
With IV access: 50 mL 50% dextrose in water solution (D50W)
Without IV access: 0.5-1 mg glucagon SQ, IV, IM and turn pt on side or observe to avoid potential aspiration from nausea and vomiting side effect
Education for pt and family regarding hypoglycemia
Prevention of future episodes:
Teach common causes
Do not change brands of insulin
S/S hypoglycemia
Medic alert bracelet
Self BG monitoring
Keep available source of CHO on person at all times
Identifying cause of episode
