10/22/15
Beyond the Blood Glucose: Nursing Care for the DKA Patient
JOSEPH M. DEFULIO, LVT SAINT FRANCIS VETERINARY CENTER WOOLWICH TOWNSHIP, NEW JERSEY
Diabetes Mellitus (DM)
u Failure of the beta (β) cells in the pancreas to produce enough insulin
u Insulin is required in order to use glucose as cellular energy
u The less insulin that is secreted, the higher the blood glucose level rises (inversely proportional; converse is also true)
1 10/22/15
Diabetic Ketoacidosis (DKA)
u Complication of Diabetes Mellitus (DM)
u Metabolic emergency
u Characterized by hyperglycemia, metabolic acidosis, ketonemia, ketonuria, dehydration, and loss of electrolytes
u REMEMBER: not all sick diabetics that are presented to the hospital are ketoacidotic, they can just be ketotic
Risk Factors
u Canine
u Median age 8 years old
u Concurrent disease in ~70% of dogs
u Acute pancreatitis, bacterial urinary tract infections (UTI), and hyperadrenocorticism
u Feline
u Median age is 9 years
u Concurrent disease in ~90% of cats
u Hepatic lipidosis, chronic renal failure, acute pancreatitis, bacterial or viral infections, and neoplasia
2 10/22/15
Clinical Signs
u Polyuria u Weakness u Polydipsia u Collapse u Polyphagia u Mental dullness
u Weight loss u Tachypnea u Vomiting u Kussmaul respiration
u Weakness u Diabetic neuropathy
Diagnostics
u Complete blood count (CBC) u Ketodiastix (serum vs. urine)
u Serum biochemistry u Urinalysis
u Electrolytes u Urine culture and sensitivity
u Venous blood gas (VBG) u +/- Pancreatic evaluation
3 10/22/15
Complete Blood Count (CBC)
u Hemoconcentration due to dehydration or anemia due to chronic disease
u Leukocytosis or left shift if there is an underlying infection or pancreatitis
u Thrombocytosis
Serum Biochemistry & Electrolytes
u Hyperglycemia – low insulin levels u Elevated total solids (TS) – dehydration u Elevated liver enzymes (ALT & ALKP) – decreased perfusion to the liver u Azotemia – pre-renal vs. renal u Hyponatremia – renal, GI loss, hyperglycemia contribution u Hypochloremia – renal, GI loss, hyperglycemia contribution u Hypokalemia – renal, GI loss, insulin administration u Hypophosphatemia – decreased body stores, insulin administration u Hypomagnesemia – renal loss u Hyperlactatemia – decreased tissue perfusion
4 10/22/15
Electrolyte Derangements
u Hypokalemia
u Most common electrolyte abnormality in critically ill veterinary patients
u Severe hypokalemia (<2 mEq/L) can result in muscle weakness causing ineffective respiration, resulting in hypoventilation and hypoxemia u Hyponatremia
u With severe hyponatremia (usually <120 mEq/L) or with rapid changes, it may be associated with CNS signs u Hypophosphatemia
u Severe hypophosphatemia can result in cellular dysfunction (i.e. hemolysis) u Hypomagnesemia
u Changes to cell membranes, other metabolic abnormalities (necessary for the movement of sodium and potassium), neuromuscular signs
Venous Blood Gas (VBG)
u Metabolic acidosis – presence of ketoacids
u Normal venous pH: 7.35-7.45
u Lower: acidic
u Higher: basic
5 10/22/15
Ketodiastix
u Subjective evaluation u Sample
u Plasma u Major types of ketones u Serum u Acetoacetate u Urine u Acetone (breakdown of acetoacetate) u β- hydroxybutyrate (usually most u Ketones are detected in serum first abundant, not detected with urine, H2O2 trick)
Ketodiastix
u Glucose (read at exactly 30 seconds) u Ketones (read at exactly 15 seconds)
u Negative u Negative
u 100 mg/dL u 5 mg/dL (trace)
u 250 mg/dL u 15 mg/dL (small)
u 500 mg/dL u 40 mg/dL (moderate)
u 1000 mg/dL u 80 mg/dL (large)
u 2000 or more mg/dL u 100 mg/dL (large)
6 10/22/15
Urinalysis (UA) & Urine Culture
u Collection method should always be cystocentesis (unless contraindicated); collect prior to starting intravenous (IV) fluid therapy and antimicrobial therapy
u Pyuria, bacteriuria, glucosuria, and ketonuria
u Excess glucose in the bloodstream and urine (must exceed renal threshold) provide a food source for bacteria
7 10/22/15
Pancreatic Evaluation
u Acute, chronic, or acute on chronic pancreatitis due to altered fat metabolism
u Methods of evaluation
u Pancreatic-specific lipase test
u Ultrasound
u Pancreatitis = painful
Vascular Access
u Maximum of 3-4 sticks (initial venipuncture, peripheral IV catheter, sampling catheter/central line)
u Large bore catheter (if possible), especially if hypovolemic or severely dehydrated
u Due to frequent sampling, an Intracath, peripherally inserted central catheter (PICC), or central line should be placed
u Always evaluate potential contraindications before placing jugular catheter
u Fluid resuscitation via peripheral IV catheter is often beneficial prior to placing a central line
8 10/22/15
Vascular Access
Over-the-needle catheter
Intracath Triple lumen catheter
Vascular Access
PREVENTS
9 10/22/15
Isotonic Crystalloids
u Plasma-Lyte A (P-Lyte), Lactated Ringers Solution (LRS), 0.9% Sodium Chloride (0.9% NaCl) – clinician preference
u REMEMBER: Dehydration ≠ hypovolemia
u Do not set it and forget it; dilution is the solution to pollution
u 75% of volume administered leaves the intravascular space within 30 minutes
u Always monitor for signs of hypervolemia
Crystalloid Additives
u Potassium phosphate (K3PO4) u Easiest to add before KCl
u Dose: 0.03-0.12 mM/kg/hr
u Calculate the phosphate first, then figure out how much potassium is included in that volume (3 mM per mL of phosphate and 4.4 mEq/mL of potassium)
u Magnesium sulfate (MgSO4) u Dose: 0.5-1 mEq/kg/day
10 10/22/15
Crystalloid Additives
u Potassium chloride (KCl) Serum K+ (mEq/L) KCl/L (mEq) <2 mEq/L 80 2.1-2.5 mEq/L 60 2.6-3.0 mEq/L 40 3.1-3.5 mEq/L 30 3.6-5 mEq/L 20 u Do not exceed Kmax (0.5 mEq/kg/hr) u Remember to subtract the volume being added from the K3PO4 (if applicable)
Additive Calculations
u Weight: 10 kg u Concentrations
u Fluids: 1L at 25 mL/hr = 40 hours u KCl: 2 mEq K+/mL
u K PO : 4.4 K+/mL & 3 mM PO 3-/mL u Potassium: 2.2 (3.6-5 mEq/L) 3 4 4
2+ u MgSO4: 4 mEq/mL Mg u Phosphorus: 1.0 (2.5-6 mEq/L)
u Magnesium: 0.7 (1.5-2.5 mEq/L)
11 10/22/15
Additive Calculations
u Step 1: Calculate phosphorus requirements
u 0.03 mM/kg/hr x 10 kg = 0.3 mM/hr
u 0.3 mM/hr x 40 hours = 12 mM to add to 1L
u 12 mM/3 mM/mL = 4 mL K3PO4 /L
u Step 2: Determine the amount of K+ in the phosphorus supplementation
+ + u 4 mL K3PO4 x 4.4 K /mL = 17.6 mEq K
Additive Calculations
u Step 3: Use the sliding scale chart to figure out the total amount of K+ supplementation is needed
u Patient’s K+ is 2.2 mEq/L
Serum K+ (mEq/L) KCl/L (mEq) <2 mEq/L 80 2.1-2.5 mEq/L 60 2.6-3.0 mEq/L 40 3.1-3.5 mEq/L 30 3.6-5 mEq/L 20
u 60 mEq of supplementation required
12 10/22/15
Additive Calculations
+ u Step 4: Subtract the total amount of K that is being added from the K3PO4 u 60 mEq – 17.6 mEq = 42.4 mEq/L
u (42.4 mEq/L) / (2 mEq/mL) = 21.2 mL KCl to the fluids
u Step 5: Ensure that you are not exceeding the Kmax u 10 kg x 0.5 mEq/kg/hr = 5 mEq/hr
u (60 mEq KCl)(40 hours) = 1.5 mEq/hr
Burettes
u Should be used for the crystalloids (not the insulin CRI), as the percentage of dextrose will be variable depending upon the BG
u No additives should be added to the primary bag of crystalloids, they should be added to the burette instead
u A fluid additive sticker should be put on the burette when necessary
u The burette should be maintained as a closed system
13 10/22/15
Insulin CRI
u Patient should be fluid resuscitated prior to starting insulin therapy
u Insulin type: Humulin R, Novolin R (regular insulin)
u Fluid type/bag size: 0.9% sodium chloride (NaCl), 250 mL bag
u Canine insulin dose: 2.2 U/kg
u Feline insulin dose: 1.1 U/kg
Insulin CRI
u Add the insulin to the fluid bag & put an additive sticker on the bag (expiration date is 24 hours later – insulin degrades in the presence of ultraviolet [UV] light)
u Attach the fluid line and bleed 50 mL out (insulin adheres to plastic)
u Begin the insulin CRI per the clinician’s orders and obtain a BG q2h
u Remember to calculate this rate into the patient’s total cumulative volume that is being administered
14 10/22/15
Insulin CRI
u The insulin CRI and crystalloids (with or without dextrose) should not be connected to one another with a blunt locking cannula; they should be administered into different access points (multi-lumen catheters simplify this)
u An appropriate pre-sample must be taken in order to reduce the risk of obtaining falsely hypo/hyperglycemic results
u Patients are typically transitioned off of the insulin CRI and onto long acting insulin when they are no longer ketoacidotic
Insulin CRI
Blood Glucose (mg/dL) CRI Rate (0.9% NaCl & Insulin) Dextrose Added to Crystalloid
>250 10 mL/hr None
200-250 7 mL/hr 2.5% Dextrose
150-200 5 mL/hr 2.5% Dextrose
100-150 5 mL/hr 5% Dextrose
<100 STOP 5% Dextrose
15 10/22/15
Intermittent IM Injections
u Patient should be fluid resuscitated prior to starting insulin therapy u Insulin type: Humulin R, Novolin R (regular insulin) u Dose: 0.2 U/kg for first injection, 0.1 U/kg for second injection (1 hour after first injection), then varies based upon BG (0.05-0.2 U/kg/hr) u Frequency of BG checks dependent upon results (start with q1 h) u Disadvantages u Frequent IM injections u Erroneous injections into adipose tissue u Can not decrease the dose once it’s given as you can with the CRI
Additional Medications
u Antimicrobial therapy
u Analgesics
u Anti-emetics
u Antacids and/or proton pump inhibitors
u Sodium bicarbonate (NaHCO3)
16 10/22/15
Blood Work Monitoring
u Frequent BG checks
u Site sample obtained from should be documented for consistency purposes
u Record units of measurement
u Frequent electrolyte checks; adjust supplementation based upon results
u Venous blood gas (VBG) analysis (improving, remaining the same, or worsening?)
u Serum biochemistry (improving, remaining the same, or worsening?)
Nutritional Considerations
u Canine & feline short term
u Hospitalized: ideally diabetic diet, consider low fat diet if pancreatitis is present, often times these patients are tempted with various diets; enteral nutrition is ideal
u Canine long term
u High fiber, low-carbohydrate diet
u Feline long term
u High protein, low-carbohydrate diet
17 10/22/15
Kirby’s Rule of 20
u Rule/parameter #20 u Tender loving care u Just as important as the medical aspect
RECOVER Lecture
u When?
u Thursday, November 19, 2015 – 1:00PM
u Thursday, November 19, 2015 – 6:30PM
u Where?
u Lecture in the Helm Center
u Wet lab in the treatment room
u Who?
u Mandatory for all staff members
18 10/22/15
Questions?
Sources
u Hess, Rebecka S. "Diabetic Ketoacidosis." Small Animal Critical Care Medicine. By Deborah C. Silverstein and Kate Hopper. 2nd ed. St. Louis, MO: Saunders/ Elsevier, 2015. 343-46. Print. u Hunter, Shannon. "Pathophysiology, Treatment and Nursing Considerations for Canine Diabetic Ketoacidosis." The NAVTA Journal (2015): 14-20. Web. 20 Oct. 2015. u Liss, David. Hold the Salt and Pass the Sugar! Management of DKA. Proc. of Atlantic Coast Veterinary Conference, Atlantic City Convention Center, Atlantic City. Print. u Randels, Angela. "Unlocking the Mystery of Diabetic Ketoacidosis (DKA)." The NAVTA Journal (2012): 23-33. Web. 20 Oct. 2015. u Saxon, William D., and Kenneth J. Drobatz. "Endocrine and Metabolic Emergencies." Manual of Small Animal Emergency and Critical Care Medicine. By Douglass K. Macintire. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2005. 359-64. Print.
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