Caring for Patients in a Metabolic Crisis of Diabetes Mellitus

1. Caring for Patients in a Metabolic Crisis of Diabetes Mellitus Diane Thompkins, RN, MS Education Specialist Dimensions Healthcare System

2. Pancreas • Function • Exocrine • Endocrine • Alpha Cells • Beta Cells • Delta Cells • Insulin/Glucagon

3. Endocrine Pancreas Function Exocrine Endocrine Alpha Cells Beta Cells Delta Cells Insulin/Glucagon

4. Function of Pancreas • Function • Exocrine • Endocrine • Alpha Cells • Beta Cells • Delta Cells • Insulin/Glucagon

5. Review of Diabetes Mellitus (DM) • Definition • Metabolic disease characterized by hyperglycemia that results from a defect in insulin secretion, insulin action or both. • Diagnosis • Clinical picture of hyperglycemia, serum hyperosmolarity, osmotic diuresis, dehydration • Symptoms

6. Symptoms Suggestive of Diabetes Mellitus          Fatigue          Polydipsia           Polyuria           Polyphagia            Weight loss Elevated fasting blood glucose

7. Review of Diabetes Mellitus • Prevalence in United States • Estimated 6.5% of general population • Occurs more often in non white Americans • Increases with age • Increasing in younger age groups

8. Comparison Between Type 1 and Type 2 Type 1Type 2 Incidence Rare: 8-24/100,00 per Most common 1/100 year per year Etiology Auto immune Multifactorial destruction of beta involving several islet cell in genetically genetic defects: strong susceptible persons: association with islet cell antibodies obesity and insulin resistance Characteristics Age of onset Rare in 1 year and Increased risk older older than 30 years: than 40 years Peak onset 11-13 years Sex Controversial: slightly Conflicting data more common in males Race 1.5 to two times more Most common in Pima prevalent in whites Indians (40-50%) and than nonwhite in Micronesia cultures: common in all races Seasonal association New onset most often No known association occurs in fall and winter Childbirth association No known association Increased incidence with increased parity Adapted from: Sauve D and Kessler C. Hyperglycemic emergencies. AACN Clinical Issues in Critical Care Nursing. 1992:3(2):353.

9. Criteria for the Diagnosis of Diabetes Mellitus • Symptoms of diabetes plus casual plasma glucose concentration  200mg/dL (11.1 mmo l/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. • FPG  126 mg/dL (7.0 mmo l/L). Fasting is defined as no caloric intake for at least 8 h. • 2-h PG  200 mg/dL (11.1 mmo l/L) during an OGTT. The test should be performed as described by the World Health Organization), using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water. In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use. FPG = Fasting Plasma Glucose 2-h PG = 2 hour Plasma Glucose OGTT = Oral Glucose Tolerance Test American Diabetes Association (2001) Clinical Practice Recommendations 2001: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, Volume 24, Supplement 1

10. Diabetes Ketoacidosis (DKA) • Etiology • Acute and serious complication of Type 1 DM • 10% all diabetes related deaths due to DKA • Complex, multisystem disorder

11. DKA HHS Mild Moderate Severe Plasma glucose (mg/dL) >250 >250 >250 Arterial pH 7.25-7.30 7.00-7.24 <7.00 Serum Bicarbonate (mEq/L) 15-18 10-<15 <10 Urine ketones* Positive Positive Positive   Serum ketones* Positive Positive Positive Effective Serum Osmolality (mOsm/kg) † Variable Variable Variable Anion gap ‡ >10 >12 >12 Alteration in sensorium or mental obtundation Alert Alert/drowsy Stupor/coma >600 >7.30 >15 Small Small >320 <12 Stupor/coma * nitroprusside reaction method; † calculation: 2[measured Na (mEq/L)] + glucose (mg/dL)18; ‡ calculation: (Na+) – (C1- + HCO3-) (mEq/L). See text for details. Reprinted with permission from the American Diabetes Association, (2001). Hyperglycemic crises in patients with diabetes mellitus. Clinical Diabetes, 19:82-90. Comparison of Clinical Findings in DKA and HHS

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13. Other Laboratory Alterations In DKA Serum K+ Usually normal or slightly elevated to 5-8 mEq/L initially (Due to acidosis) <3.5 mEq/L within hours (Due to osmotic diuresis) Serum PO4+ Usually elevated to 6-7 mg/dL Serum Na+ Slightly reduced to 125-130 mEq/L BUN and Creatinine Elevated (Due to dehydration: decreased glomerular filtration rate, fluid deficit, and protein catabolism)

14. DKA: Diagnostic Findings • Pulmonary • Cardiovascular • Neurologic • GI/GU

15. Management of Adult Patients with DKA

16. Hyperosmolar Hyperglycemic Syndrome (HHS) • Etiology • Acute and serious complication of Type 2 Diabetes • concurrent illness • pharmacological • enteral or parentral feedings • peritoneal dialysis • elder abuers • failure to take hypoglycemic medications

17. Hyperosmolar Hyperglycemic Syndrome (HHS) • Etiology • Diagnosis • severe hyperglycemia  600mg/dL • profound dehydration • mild or undetectable ketonuria • absence of ketosis

18. Hyperosmolar Hyperglycemic Syndrome (HHS) • Other terminology use for HHS • Hyperosmolar nonacidotic diabetes • Hyperosmolar nonketotic coma • Hyperglycemia hyperosmolar nonketotic state or syndrome • Diabetic hyperosmolar state • Hyperosmolar coma • Hyperosmolar nonacidotic uncontrolled diabetes

19. Hyperosmolar Hyperglycemic Syndrome (HHS) • Pathophysiology • Hyperglycemia result of some combination of the following: • deficient insulin production • decreased tissue responsive to insulin • increased levels of counter regulatory hormones e.g. glucagon, growth hormone

20. Metabolic Stressors Associated with HHS

21. Hyperosmolar Hyperglycemic Syndrome (HHS) • Clinical Presentation • Patient • type 2 diabetes • age • vulnerable or institutionalized patients • fluid depleted patients

22. Hyperosmolar Hyperglycemic Syndrome (HHS) • Clinical Presentation • Signs & Symptoms • ketoacidosis does not develop • seen by health care providers because of impaired mental status • hyperglyemia, hyperosmolality, and osmotic diuresis • more neurologic abnormalities than DKA • may be misdiagnosed as having a stroke • hypotension due to osmotic diuresis

23. Diagnostic Findings: Laboratory Alterations In HHS Serum K+ Usually normal or slightly elevated to 5-8 mEq/L initially (Due to intracellular to extracellular shift) Serum PO4+ Usually elevated to 6-7 mg/dL Serum Na+ Slightly reduced to 125-130 mEq/L (Not an accurate reflection of the patient's osmolality) BUN and Creatinine Elevated (Due to dehydration) Adapted from: Clark. Hypersomolar nonacidotic diabetes (HNAD). In: Urban N, Greenlee K, Krimberger J, and Winkelman C, eds. Guidelines for Critical Care Nursing. St. Louis: Mosby Yearbook; 1995:550-555

24. Depressed mental status, stuporous, Tachypnea with hypoxemia Tachycardia EKG with peaked T waves due to hyperkalemia Profound dehydration, constipation Hyperosmolar Hyperglycemic Syndrome (HHS)

25. DKA HHS Mild Moderate Severe Plasma glucose (mg/dL) >250 >250 >250 Arterial pH 7.25-7.30 7.00-7.24 <7.00 Serum Bicarbonate (mEq/L) 15-18 10-<15 <10 Urine ketones* Positive Positive Positive   Serum ketones* Positive Positive Positive Effective Serum Osmolality (mOsm/kg) † Variable Variable Variable Anion gap ‡ >10 >12 >12 Alteration in sensorium or mental obtundation Alert Alert/drowsy Stupor/coma >600 >7.30 >15 Small Small >320 <12 Stupor/coma * nitroprusside reaction method; † calculation: 2[measured Na (mEq/L)] + glucose (mg/dL)18; ‡ calculation: (Na+) – (C1- + HCO3-) (mEq/L). See text for details. Reprinted with permission from the American Diabetes Association, (2001). Hyperglycemic crises in patients with diabetes mellitus. Clinical Diabetes, 19:82-90. Comparison of Clinical Findings in DKA and HHS

26. Hyperosmolar Hyperglycemic Syndrome (HHS) • Management • Fluid • Replace electrolytes • Monitor signs/symptoms of imbalances • Insulin • Patient Teaching

27. Management of Adult Patients with HHS*

28. Case Study