Otterbein University Digital Commons @ Otterbein

Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work

Fall 2014

Management of a DKA Patient with Severe Metabolic and Ketoacidosis with Chronic Renal Insufficiency

Brian Albany Otterbein University, [email protected]

Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn

Part of the Endocrine System Diseases Commons, Medical Pathology Commons, and the Nursing Commons

Recommended Citation Albany, Brian, "Management of a DKA Patient with Severe Metabolic and Ketoacidosis with Chronic Renal Insufficiency" (2014). Nursing Student Class Projects (Formerly MSN). 6. https://digitalcommons.otterbein.edu/stu_msn/6

This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected]. Management of a DKA patient with severe metabolic and ketoacidosis with chronic renal insufficiency Brian Albany BSN, CCRN Otterbein University, Westerville, Ohio Introduction Case Study Underlying Significance of Pathophysiology Implications for nursing care References

Pathophysiology • Identify if the patient with DKA has [1] Bailey, J. L. (2013). Insulin Resistance and Muscle Metabolism in Chronic Diabetic ketoacidosis (DKA) A 55 year old female patient with a Healthcare providers are able to tailor case-specific treatment through an in- renal insufficiency Kidney Disease. ISRN Endocrinology, 1-14. doi:10.1155/2013/329606 serves as one the leading causes of past medical history of type one depth analysis and dissection on the pathophysiological processes associated with a • Draw serial labs: Chem 7, Beta [2] Brown, C., Watson, W., Morrison, I., & MacLennan, K. (2014). Novel methods of mortality in diabetic patients [14]. diabetes and end-stage renal disease patient in DKA with a comorbidity of chronic kidney disease. The goal of treatment hydroxybutyrate, and ABGs q 6 teaching diabetic ketoacidosis ( DKA) diagnosis and management in a The mortality has decreased over presents to the intensive care unit with for DKA is to reduce serum glucose levels and ketoacidosis through the hours clinical curriculum: Sim- DKA. Practical Diabetes, 31(5), 207-211. the past several decades due to the diabetic ketoacidosis. The patient had administration of parental insulin. This will ultimately result in the improvement of • Consult with physician to obtain doi:10.1002/pdi.1868 rapid recognition of the disease the following lab values: acidosis and will produce a state of acid-base homeostasis. This may not be an order to administer sodium [3] Csaba, K. P. (2013, October 8). Pathogenesis, consequences, and treatment of state and the improvement of effective solution to follow in patients who present with severe metabolic and bicarbonate if pH<6.9 metabolic acidosis in chronic kidney disease (R. H. Sterns & J. P. Forman, management of DKA [14]. Despite a • Glucose-1,107 mg/dL ketoacidosis. • Monitor hourly blood glucose level Ed.). Retrieved October 2, 2014, from UpToDate website: decline in mortality rates over the • Beta hydroxybutyrate-7.6 Insulin resistance is defined as “a clinical condition where there is a reduced • Follow DKA protocol for fluid http://www.uptodate.com past twenty years from 7.96% to mg/dL biological effect for any given blood concentration of insulin,” [8]. It is characterized management strategy [4] Farwell, W., & Taylor, E. (2008). Serum bicarbonate, anion gap and insulin 0.67%, errors in management of the • Anion Gap-36 mEq/l as reduced tissue responses to the action of insulin [1]. One study concluded that • Provide electrolyte resistance in the National Health and Nutrition Examination disease state are associated with • Creatinine-4.54 mg/dL there is a direct relationship between a lower serum bicarbonate and high anion supplementation as blood glucose Survey. Diabetic Medicine, 25(7), 798-804. significant morbidity and mortality • BUN-80 mg/dL gap which are both independently associated with reduced insulin sensitivity [4]. levels normalize [5] Guneysel, O., Guralp, I., & Onur, O. (2008). Bicarbonate therapy in diabetic [2]. Utilization of DKA protocols in • GFR-<5ml/min The data from this study supports the hypothesis that the production of organic • Call physician to transition patient ketoacidosis. Bratislavské Lekárske Listy, 109(10), 453-454. the acute care setting have allowed • Lactate-4.1 mg/dL acid serves as a central feature of insulin resistance [4]. The use of alkali therapy in onto subcutaneous insulin when [6] Kobayashi, S., Maesato, K., Moriya, H., Ohtake, T., & Ikeda, T. (2005). Insulin congruency in care and delivery of DKA is controversial because the acidosis should correct itself through the anion gap closes resistance in patients with chronic kidney disease. American Journal Of Kidney effective lifesaving treatment. ABG: administration of insulin and fluids; however, many studies show that insulin Diseases, 45(2), 275-280 Despite advances in standardized • pH-6.85 sensitivity is decreased in uremic patients; therefore, treatment of metabolic [7] Kraut, J., & Madias, N. (2011). Consequences and therapy of the metabolic acidosis DKA protocols, there still remains a • Co2-12 mmHg Figure 1: Pathological process of acidosis through alkali therapy is necessary in achieving a decrease in insulin of chronic kidney disease. Pediatric Nephrology, 26(1), 19-28. gap in how to manage specific • HCO3-1.9 mmol/L DKA [15] resistance with patients that also present with end stage renal disease [1,9,11,13]. doi:10.1007/s00467-010-1564-4 patient populations with end stage • PO2-197 mmHg Data suggests that acidosis should be corrected as soon as possible which will Conclusion [8] Mak, R. H. (2008). Insulin and its role in chronic kidney disease. Pediatric renal disease. Understanding the DKA develops as a result deficient result in increased insulin sensitivity to lower blood glucose levels and decrease Nephrology, 23(3), 355-362. doi:10.1007/s00467-007-0611-2 pathophysiology behind these These lab values indicate the levels of insulin circulating throughout the lipolysis [6]. The exogenous insulin given to treat patients in DKA is insensitive and The current standardized [9] Mak, R. K. (1998). Effect of metabolic acidosis on insulin action and secretion in patient populations will yield better combination of severe ketoacidosis from body causing a triad of hyperglycemia, ineffective without neutralizing the blood pH through bicarbonate therapy in such DKA protocols do not address uremia. Kidney International, 54(2), 603-607. doi:10.1046/j.1523- outcomes with the ultimate goal of DKA and metabolic acidosis related to hyperketonemia, and acidosis [10,14]. extreme circumstances. The American Diabetes Association states how severe patients with renal insufficiency. 1755.1998.00023.x decreasing the mortality rate. chronic renal insufficiency. Counterregulatory hormones consisted of acidosis in hyperglycemic crises can lead to more adverse effects and that adult Treatment for diabetic patients [10] McCance, K. L., & Huether, S. E. (2014). Pathophysiology the biologic basis for The patient arrives to the intensive catecholamines, glucagon, and cortisol are patients with a pH < 6.9 should receive sodium bicarbonate until pH>7.0 is in DKA with chronic kidney disease in adults and children (7th ed.) (V. L. Brashers & N. S. Rote, Eds.). St. care unit with an intact neurological activated in a state of insulin deficiency achieved [5]. disease should revolve around Louis, MO: Elsevier. status, stable vital signs, and on room ultimately causing an increased blood The kidneys play a major role in metabolism of insulin [12]. Approximately correcting extreme metabolic [11] Min-Tser, L., Chih-Chien, S., Kuo-Chin, H., Chia-Chao, W., Lan, L., & Kuo-Cheng, L. air. The nurse titrated the insulin drip glucose level. The glucagon activates 25% of daily insulin production is degraded by the kidneys [12]. Renal metabolism acidosis states (pH<6.9) before (2012). Insulin Resistance in Patients with Chronic Kidney Disease. Journal Of per hospital’s DKA policy. This policy gluconeogenesis in the liver to form more is augmented in diabetic patient’s receiving exogenous insulin because the insulin the administration of parental Biomedicine & Biotechnology, 20121-12. doi:10.1155/2012/691369 states that the nurse is able to double glucose and the body starts to break down bypasses filtration through the liver when injected into the systemic circulation insulin. This approach will [12] Palmer, B. F., & Henrich, W. L. (2013, June 6). Carbohydrate and insulin the insulin infusion rate if the blood adipose tissue through lipolysis which [12]. Since the renal clearance of insulin is 200ml/min, patients with an impaired increase insulin sensitivity and metabolism in chronic kidney disease (J. S. Berns & A. M. Sheridan, Ed.). glucose level has not decreased after yields free fatty acids and a state of GFR will have unfiltered insulin freely circulating in the body [12]. This becomes utilization to decrease blood Retrieved from UpToDate website: http://www.uptodate.com initiating the drip. The patient’s blood hyperketonemia. The circulating ketones significant when treating a DKA patient with renal insufficiency. Administering glucose levels and halt the [13] Siew, E., & Ikizler, T. (2010). Insulin resistance and protein energy metabolism in glucose had not improved despite induces a state of acidosis with a exogenous IV insulin to this patient without correcting the patient’s acidosis can process of lipolysis, ultimately patients with advanced chronic kidney disease.Seminars In Dialysis, 23(4), 378- intravenous IV insulin; therefore, the decreased bicarbonate reserve. Severe result in serious adverse outcomes and even death by inducing a state of resolving DKA. 382. doi:10.1111/j.1525-139X.2010.00763.x nurse titrated the drip up to 100 dehydration and electrolyte abnormalities hypoglycemia. The patient’s extreme metabolic acidosis will result in a decreased [14] Solá, E., Garzón, S., García-Torres, S., Cubells, P., Morillas, C., & Hernández- units/hr. At the same time, the patient occur as the result of osmotic diuresis insulin sensitivity and a decreased ability to filter insulin out of the body; therefore, Mijares, A. (2006). Management of diabetic ketoacidosis in a teaching received 2 amps of sodium bicarbonate associated with the hyperglycemic state the patient is at risk for developing hypoglycemia when the acidosis is corrected. hospital. Acta Diabetologica, 43(4), 127-130 IV push and was started on a sodium [10]. This concept was evident in the case study when the patient’s blood glucose levels [15] Diabetic ketoacidosis flowchart [Illustration]. (n.d.). Retrieved from bicarbonate infusion. After some time, Patients with chronic kidney disease had dramatically declined the following day due to increased levels of circulating http://pixgood.com/diabetic-ketoacidosis-flowchart.html the patient’s labs started to trend in the often develop a common complication of insulin along with the correction of the patient’s acidosis [16] [Diagram of DKA process]. (2010, August 31). Retrieved from right direction with a closing anion gap, metabolic acidosis [3,7]. A state of ph http://vetbook.org/wiki/cat/index.php/Diabetic_ketoacidosis decrease in glucose level, increase in pH homeostasis is usually maintained by the and decrease in ketone levels. The functional units of the kidneys or nephrons insulin infusion rate ran at a rate of through the excretion of ammonia with a 100units/hr for a total of 5 hours then it normal glomerular filtration rate (GFR). was weaned off based on the closure of When the GFR reaches a dysfunctional the anion gap and decrease in the state of below 40ml/min, there is a patient’s glucose level. decrease in ammonium excretion and an During day shift, the patients’ blood increase in hydrogen ion retention causing glucose plummeted into the low 40s on a state of acidosis [3]. Other key factors three different occasions. Each time, the that contribute to the acidosis are the nurse gave 1 amp of Dextrose 50%. decreased synthesis of the acid buffer bicarbonate and the increased excretion of the bicarbonate through the gastrointestinal and urinary tract [7]. Figure 2: Three elements of DKA [16]