COMPLICATIONS Kacy Aderhold, MSN, APRN-CNS, CMSRN

ACUTE COMPLICATIONS

Hyperglycemia

Hypoglycemia

DKA

HHS

HYPERGLYCEMIA

Signs/Symptoms are caused by high glucose levels

and the body’s effort to get rid of the extra sugar:

• Higher BS than usual

• Increased urine output

• Increased thirst

• Increased hunger

• Dry skin and mouth

• Dehydration

• Fatigue

• Blurred vision

HYPERGLYCEMIA TREATMENT

Lifestyle Interventions

Insulin

Oral Agents

PATIENT EDUCATION

HYPOGLYCEMIA

Blood glucose < 70

Severe hypoglycemia < 40

Early recognition and treatment of hypoglycemia

can prevent deterioration to a more severe

episode with potential adverse outcomes!

(ADA, 2015)

HYPOGLYCEMIA SIGNS & SYMPTOMS

Adrenergic • Pallor

• Diaphoresis

• Tachycardia

• Shakiness

• Hunger

• Anxiety

• Irritability

• Headache

• Dizziness

Neuroglycopenic

• Confusion

• Slurred Speech

• Irrational behavior

• Extreme fatigue

• Disorientation

• Loss of consciousness

• Seizures

• Pupillary sluggishness

• Decreased response

RISK FACTORS FOR HYPOGLYCEMIA

Altered nutritional state

Heart failure, renal, or

liver disease

Malignancy

Infection

Sepsis

Sudden reduction in

corticosteroid dose

Altered ability of patient

to report symptoms

Reduction in oral intake

New NPO status

Inappropriate timing of

short- or rapid-acting

insulin

Reduction of IV

dextrose

Unexpected

interruption of TPN/TF

DR. PHIL CRYER’S THERMOMETER

HYPOGLYCEMIA MANAGEMENT STANDING ORDERS

Patient able to swallow safely and not NPO:

15/15 Rule!

Patient unable to swallow safely and/or NPO:

(100 – FSBS) x 0.3 = # mL of D50 IV

No IV Access:

Glucagon 1mg IM or Subcut

HYPOGLYCEMIA MANAGEMENT STANDING ORDERS

Examples of 15 grams of carbs:

• 4 oz. juice or regular pop

• 8 oz. milk (skim preferred)

• 4 pkgs sugar mixed with

water (good for fluid or

potassium restriction)

• REMEMBER: You must

recheck a FSBS 15

minutes after each

reading below 70mg/dL.

• Notify physician before the

next insulin dose or oral

anti-diabetic medication

dose if FSBS less than 70

• Don’t forget to Document!

If FSBS < 70 mg/dL, give 15 grams of carbs, wait 15 minutes and recheck

FSBS; Repeat if necessary until FSBS is > 70mg/dL

15/15 RULE FOR HYPOGLYCEMIA

HYPOGLYCEMIA MANAGEMENT STANDING ORDERS

If patient is hypoglycemic &

unable to swallow safely or NPO:

(100 – FSBS) x 0.3 = # mL of D50 IV

How much D50 would you give to a

patient with a blood glucose of 59?

12 mL of D50 IV

HYPOGLYCEMIA MANAGEMENT STANDING ORDERS

If patient is hypoglycemic and has no IV access:

Glucagon 1mg IM or Subcut

HOW DID THEY DO ON THEIR DOCUMENTATION?

DIABETIC KETOACIDOSIS (DKA) &

HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)

DKA & HHS are the most serious complications seen with hyperglycemia (Kaplow & Hardin, 2007)

Preventable complications

Similar presentation

Different time of onset, degree of dehydration, & severity of ketosis

DKA & HHS were the first listed diagnosis in 175,000 ED visits in 2011 (CDC, 2014)

In 2010, hyperglycemic crises caused 2,361 deaths in adults aged 20 years or older

DIABETIC KETOACIDOSIS

(Kitabchi & Razavi, 2009)

(UCSF, 2014)

DIABETIC KETOACIDOSIS

Most common in patients with Type 1 Diabetes

Patients with Type 2 Diabetes are at risk during

catabolic stress

Responsible for >500,000 hospital days/year

Estimated annual expense of $2.4 billion

Mortality in adult patients is <1%

Mortality is >5% in elderly patients & patients

with severe comorbidities

Mortality r/t underlying precipitating illness

(ADA, 2009)

DKA PRECIPITATING FACTORS

Infection

Discontinuation of or inadequate insulin therapy

Acute illness

Pancreatitis

MI

CVA

Alcohol or drug intoxication

Undiagnosed Type 1 Diabetes

(Kaplow & Hardin, 2007)

SYMPTOMS OF DKA

Polyuria

Excessive thirst

Weakness, fatigue

Nausea, vomiting

Stomach pain

Heavy, deep breathing

Fruity breath – the smell of ketoacids

Speech problems, confusion or unconsciousness

(Kaplow & Hardin, 2007)

HYPEROSMOLAR HYPERGLYCEMIC STATE

Severe hyperglycemia

Dehydration

Hyperosmolality

Absence of significance of ketoacidosis

(Kaplow & Hardin, 2007)

HYPEROSMOLAR HYPERGLYCEMIC STATE

Also known as Hyperosmolar Hyperglycemic

Non-Ketotic Syndrome (HHNS)

Most commonly in older adults with Type 2

Diabetes (Kaplow & Hardin, 2007)

Mortality 5-20% (ADA, 2009)

HHS PRECIPITATING FACTORS

Infection

Discontinuation of or

inadequate insulin therapy

Endocrine Disorders

Acromegaly

Thyrotoxicosis

Cushing’s Syndrome

Drugs

Undiagnosed Diabetes

Acute Illness

CVA

MI

Pancreatitis

PE

Intestinal obstruction

PD

Acute Renal Failure

Severe Burns

Subdural hematoma

Mesenteric thrombosis

Heat Stroke

Hypothermia

(Up To Date, 2014)

SYMPTOMS OF HHS

Polyuria

Polydipsia

Weight Loss

Neurological Symptoms

Focal neurologic signs (hemiparesis or hemianopsia)

Seizures

Mental obtundation

Coma

(ADA, 2009)

PATHOGENESIS OF DKA AND HHS

(ADA, 2009)

DIAGNOSTIC CRITERIA

BMP

Plasma glucose

BUN

Creatinine

Electrolytes

Anion Gap

Osmolality

Serum ketones

ABGs

CBC with differential

EKG

CXR

UA & Culture, urinary ketones

Sputum Culture

Blood Cultures

(ADA, 2009)

DKA & HHS DIFFERENTIAL DIAGNOSIS

(ADA, 2009)

DKA HHS

Mild (plasma

glucose

>250mg/dl)

Moderate

(plasma glucose

>250 mg/dl)

Severe (plasma

glucose

>250mg/dl)

Plasma Glucose

>600mg/dl

Arterial pH 7.25-7.30 7.00 to <7.24 <7.00 >7.30

Serum

Bicarbonate

15-18 10 to <15 <10 >18

Urine Ketone Positive Positive Positive Small

Serum Ketone Positive Positive Positive Small

Effective

Serum

Osmolality

Variable Variable Variable >320 mOsm/kg

Anion Gap >10 >12 >12 Variable

Mental Status Alert Alert/Drowsy Stupor/Coma Stupor/Coma

DKA MAIN TREATMENT PRINCIPLES

Continuous insulin & fluid replacement until

ketosis has resolved

Insulin Infusion MUST continue along with sufficient

glucose intake to prevent hypoglycemia

DO NOT stop insulin infusion until ketoacidosis and

dehydration resolve, patient is eating, and

intermediate or long acting insulin is administered

Identify precipitating factors & treat concurrent

illness as indicated.

TREATMENT OF DKA

Restore fluid volume

Initial NS bolus, then maintenance at 250mL/hr

When FSBS < 175mg/dL, add 5% dextrose

D51/2NS20K 150/hr if K+ <5 and urine output is > 0.5mL/kg/hr

D51/2NS 150/hr if K+ >5 or urine output is < 0.5mL/kg/hr

Subsequent fluids depend on hemodynamics, hydration status, electrolyte levels and urine output

Correct hyperglycemia

Initial IV bolus 10 units regular insulin

Continuous IV insulin infusion with regular insulin per protocol

TREATMENT OF DKA (CONT.)

Potassium

Insulin therapy, correction of acidosis, and

volume expansion decrease serum K+

If K+ < 5 and urine output < 0.5 mL/kg/hr,

potassium is added to maintenance fluid

Frequent patient monitoring

Electrolytes, BUN, venous pH, creatinine, urinary

output & blood glucose

(ADA, 2009)

CRITERIA FOR DKA RESOLUTION

Initiate Hyperglycemia Management Protocol when:

CO2 > 16

Anion gap < 16

Patient is ready to eat solid food

Fluid deficit is corrected

(ADA, 2009)

CASE STUDY

A 45 y/o male presents to the ER with s/s of DKA.

Patient has T1DM x 10 yrs. Patient’s labs and

assessment reveal moderate DKA and a critical

K+ of 6.0. The patient is treated with Kayexalate

to correct K+. The patient is started on fluids and

then an insulin infusion. Patient is admitted to

the ICU. 4 hours later the patient’s insulin

infusion is up to 28 units/hr. K+ is now 1.9 and

FSBS is 45.

Provider who will manage DM after discharge

Assess need for HH or outpatient DM education

Diagnosis

SMBG & home goals

Information on consistent eating patterns

When & how to take BG lowering medications

Sick day management

Proper use & disposal of needles & syringes

SURVIVAL SKILLS DISCHARGE EDUCATION

(ADA, 2015)

SICK DAY MANAGEMENT EDUCATION

Early contact with healthcare provider

Importance of insulin during illness and the

reasons never to discontinue without contacting

the healthcare team

Review of blood glucose goals and the use of

supplemental short or rapid-acting insulin

Having medications available at home to

suppress fever and treat infection

Initiation of an easily digestible diet containing

carbs and salt if nauseated

(ADA, 2015)

CHRONIC COMPLICATIONS

Heart Disease

Stroke

Hypertension

Eye Problems

Kidney Disease

Depression

Nervous System Damage

Vascular Disease

Gastroparesis

Amputations

CHRONIC COMPLICATIONS

In 2008, 23.6 million Americans had diabetes

In 2012, 29.1 million Americans have diabetes

“The rise in diabetes prevalence data results from

both the fact that more people are developing the

disease and the fact that people are living longer

with it, thanks to better management of

cardiovascular risk factors and fewer complications

such as renal failure and amputations.” (Tucker,

2011)

COST OF DIABETES

Estimated total national cost of diagnosed

diabetes is $245 billion.

$69 billion in indirect costs (disability, work

loss, premature mortality)

Average medical expenditure among people with

diabetes is 2.3 times higher than those without

One in five health care dollars is spent caring

for people with diabetes.

(CDC, 2014)

MACROVASCULAR COMPLICATIONS

MI, CVA, CAD, PAD

2 out of 3 people with diabetes die from heart

disease or stroke

Atherosclerosis process:

Accounts for ~80% of all diabetes-related mortality

Occurs at earlier age, advances more rapidly

DM alone accelerates the development of

atherosclerosis 200-400%

CEREBROVASCULAR DISEASE

Cerebral vascular disease mortality is 3-5

times higher in patients with DM

CARDIOVASCULAR DISEASE (CVD)

Every 1% increase in A1c increases CVD by 14%

MI is the #1 cause of death for people with DM

Patients with DM have a 30% higher risk for CVD

CVD death rates are 1.7 X higher among adults with DM

1.8 X higher MI hospitalization rates for patients with DM

1.5 X higher hospitalization rates for adult patients with DM

20-50% of patients with DM have asymptomatic, silent

ischemia

HYPERTENSION

• 71% of adults with diabetes aged 18 years or

older have a blood pressure > 140/90 (CDC, 2014)

• ADA Standards of Medical Care recommend

treating patients to a goal of <140/90 mmHg (ADA, 2015)

• Lower targets (such as <130/<80 mmHg) may be

appropriate for certain individuals, such as

younger patients (ADA, 2015).

PERIPHERAL ARTERY DISEASE (PAD)

• Blood vessels in feet and legs are narrowed or

blocked by fatty deposits.

• Blood circulation decreases, leading to slow healing

of wounds.

• PVD & neuropathy account for 50% of all non-

traumatic lower extremity amputations

MICROVASCULAR COMPLICATIONS

Retinopathy

Nephropathy

Neuropathy

Intensive insulin therapy improves the outcome

of microvascular disease!

DIABETIC RETINOPATHY

Diabetes is the leading cause of new cases of blindness

among adults in the U.S.

Small blood vessels in retina are damaged

Glaucoma and cataracts occur more frequently in

patients with DM

No early warning symptoms

(CDC, 2014)

DIABETIC RETINOPATHY PREVENTION

Blood pressure control

Blood glucose control

Lipid control

Early detection-

annual dilated eye

exam

KIDNEY DISEASE

DM is the leading cause of kidney failure.

49,677 people began tx for kidney failure due to DM in 2011

228,924 people with kidney failure due to DM were living on

chronic dialysis or with a kidney transplant in 2011.

Small blood vessels in the nephrons of kidneys are damaged

Hypertension accelerates progression of nephropathy

No early warning signs or symptoms

(CDC, 2011)

NERVOUS SYSTEM DAMAGE

60-70% of people with

diabetes have mild to

severe forms of

nervous system

damage.

Nerve damage can

result in pain in feet

or hands, slowed

digestion, sexual

dysfunction or other

nerve problems.

(CDC, 2011)

PERIPHERAL NEUROPATHY

Most common long-term complication of diabetes

Progressive microvascular damage

Described as numb, tingling, pins and needles, dead,

shooting, stabbing, knife-like, gnawing, electrical,

burning, hypersensitive

Damage is distal & symmetrical, feet affected 1st

Treatment:

The first step is stabilization of blood glucose

Anticonvulsants, SNRIs, Tricyclic antidepressants

AMPUTATIONS

Amputation rates 10X higher in patients with DM

In 2010, 73,000 non-traumatic lower-limb amputations

were performed in adults with DM

Increased rates in men, African Americans, Hispanics,

American Indians

Risk factors for patients with DM:

Loss of protective sensation related to neuropathy

Decreased circulation related to PVD & PAD

Impaired vision may cause patient to not notice wound

Increased risk for infection

Decreased wound healing

(CDC, 2011)

FOOT PROBLEMS

• Diabetes

increases risks

for foot problems

Foot Care Video

(Illumistream, 2007)

FOOT CARE Wash your feet daily with soap and warm water.

Dry your feet gently with soft towel.

If your skin is dry, apply lotion (but not between toes).

Examine tops, bottoms, and sides of feet and between toes. Use a mirror to

help see the bottoms and sides of feet. Or get help from a family member.

Check for sores, cuts, bruises, rashes, blisters, red spots, swelling, and

ingrown toenails.

Use your hands to feel for hot or cold spots, bumps, or dry skin.

If you have a foot injury, call your healthcare provider. Do not try to take care

of foot injuries yourself. Some over-the-counter foot remedies can harm your

skin, making injuries worse.

Trim your toenails straight across and file the edges. Rounded edges help

prevent ingrown toenails.

Choose socks that will not irritate your feet, such as seamless socks or those

with flat or soft seams.

Before you put on shoes, feel inside them to make sure there are no pebbles

or rough edges that might injure your feet. You may not be able to count on

the nerves in your feet to feel something wrong with your shoes or socks.

Protect your feet all the time by wearing shoes or slippers, even around the

house, pool, or beach.

(Illumistream, 2007)

GASTROPARESIS

Symptoms:

Frequent nausea

Vomiting undigested meals

Early satiety

Bloating

Erratic blood glucoses

Treatment:

Low fat, low fiber diet

Multiple, small meals- mostly liquid

metoclopramide, domperidone

Gastric pacemaker

Hemigastrectomy

Jejunostomy

DEPRESSION

People with diabetes are twice as likely to have

depression

Depression is associated with a 60% increased

risk of developing type 2 diabetes

(CDC, 2011)

Measure ADA Standard Goal

A1c <7%

Blood Pressure <140/90, lower targets may be

appropriate for some

Dilated Eye Exam At least once a year

Foot Exam Check feet every day

Foot exam with monofilament annually

Smoking STOP!!!

LDL (mg/dL) <100 mg/dL if no known CVD

<70 mg/dL if known CVD

Triglycerides (mg/dL) <150 mg/dL

HDL (mg/dL) >40 mg/dL in men

>50 mg/dL in women

GOALS TO PREVENT COMPLICATIONS

REFERENCES American Diabetes Association (2015). Standards of Care. Diabetes Care 38 (1), S1-

S99.

American Diabetes Association. (2009). Hyperglycemic crises in adult patients with

diabetes (consensus statement). Diabetes Care 32(7), 1335-1343.

Centers for Disease Control (2011) National Diabetes Fact Sheet, 2011. National

Center for Chronic Disease Prevention and Health Promotion.

http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Illumistream (2007). Diabetes Foot Care for Diabetes #2. Clip Syndicate. Retrieved

on March 11, 2014 from

http://www.clipsyndicate.com/video/playlist/8317/409571?title=illumistream_at_clips

yndicate

Diabetes Education Online (2014). Diabetic ketoacidosis. Diabetes Teaching Center at

the University of California, San Francisco. Retrieved on February 25, 2014 from

http://dtc.ucsf.edu/living-with-diabetes/complications/diabetic-ketoacidosis/

Kaplow, R. & Hardin, S. (2007). Critical Care Nursing: Synergy for Optimal

Outcomes. MA: Jones & Bartlett.

Kitabchi, A.E. (2014). Clinical features and diagnosis of diabetic ketoacidosis and

hyperosmolar hyperglycemic state in adults. Up To Date. Retrieved on February 25,

2014 from http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-

diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults

Tucker, M. (2011). Diabetes prevalence keeps climbing in the U.S. Clinical

Endocrinology News, 6 (2), 1.