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 Neuroglycopenic • Pallor • Confusion • Diaphoresis • Slurred Speech • Tachycardia • Irrational behavior • Shakiness • Extreme fatigue • Hunger • Disorientation • Anxiety • Loss of consciousness • Irritability • Seizures • Headache • Pupillary sluggishness • Dizziness • Decreased response

RISK FACTORS FOR HYPOGLYCEMIA

 Altered nutritional state  Reduction in oral intake  Heart failure, renal, or  New NPO status liver disease  Inappropriate timing of  Malignancy short- or rapid-acting  Infection insulin  Sepsis  Reduction of IV dextrose  Sudden reduction in corticosteroid dose  Unexpected interruption of TPN/TF  Altered ability of patient to report symptoms

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 15/15 RULE FOR HYPOGLYCEMIA

If FSBS < 70 mg/dL, give 15 grams of carbs, wait 15 minutes and recheck FSBS; Repeat if necessary until FSBS is > 70mg/dL

Examples of 15 grams of carbs: • REMEMBER: You must • 4 oz. juice or regular pop recheck a FSBS 15 minutes after each • 8 oz. milk (skim preferred) reading below 70mg/dL. • 4 pkgs sugar mixed with water (good for fluid or • Notify physician before the potassium restriction) next insulin dose or oral anti-diabetic medication dose if FSBS less than 70 • Don’t forget to Document! 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  Acute Illness

 Discontinuation of or  CVA inadequate insulin therapy  MI  Pancreatitis  Endocrine Disorders  PE  Acromegaly  Intestinal obstruction  Thyrotoxicosis  PD  Cushing’s Syndrome  Acute Renal Failure  Drugs  Severe Burns  Undiagnosed Diabetes  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

DKA HHS Mild (plasma Moderate Severe (plasma Plasma Glucose glucose (plasma glucose glucose >600mg/dl >250mg/dl) >250 mg/dl) >250mg/dl)

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

Serum 15-18 10 to <15 <10 >18 Bicarbonate Urine Ketone Positive Positive Positive Small

Serum Ketone Positive Positive Positive Small

Effective Variable Variable Variable >320 mOsm/kg Serum Osmolality

Anion Gap >10 >12 >12 Variable

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

(ADA, 2009) 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. SURVIVAL SKILLS DISCHARGE EDUCATION

 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

(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) GOALS TO PREVENT COMPLICATIONS

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 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.