Diabetic Emergencies

I. Definition:
Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. Diabetic ketoacidosis develops when your body is unable to produce enough insulin and an increase in insulin counter-regulatory hormones (catecholamines, cortisol, glucagon and growth hormone). Insulin normally plays a key role in helping sugar (glucose) a major source of energy for your muscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a build-up of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

II. Predisposing Factors:

An illness. An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits. A problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis. Other possible triggers of diabetic ketoacidosis may include: Stress Physical or emotional trauma High fever Surgery Heart attack Alcohol or drug abuse, particularly cocaine Factors that antagonize insulin such as steroids use, glucagon and growth hormones; lipolysis

III. Epidemiology:
A. PREVALENCE o In the landmark Diabetes Control and Complications Trial, the rate of DKA in adults on the conventional insulin protocol was 1.8 per 100 person-years compared to a rate of 2.0 per 100 person-years in those on an intensive insulin protocol o DKA is a common finding at the time of diabetes presentation, occurring in 29% of patients with type 1 diabetes and 10% of patients with type 2 diabetes o From 1985 to 2005, there was a 42% increase in the number of hospitalizations for DKA B. MORTALITY
o Overall mortality rate for adults is less than 1% o Mortality rate in the elderly and in patients with significant comorbidities is greater than 5% o Most common cause of death in children and adolescents with type 1 diabetes

C. ECONOMIC IMPACT
o Results in more than 500,000 hospital days per year in the U.S. o Direct and indirect cost of 2.4 billion U.S. dollars annually

D. AGE
o 18% are under age 20 o 56% are aged 18 to 44 years o 24% are aged 45 to 65 years

E. RACE
o Slightly more predominant in whites (45% non-whites).

IV. Clinical Signs and Symptoms:

Excessive thirst Frequent urination Nausea and vomiting Abdominal pain Weakness or fatigue Shortness of breath Fruity-scented breath Confusion More-specific signs of diabetic ketoacidosis which can be detected through home blood and urine testing kits include: High blood sugar level (hyperglycemia) High ketone levels in your urine

V. Laboratory Results and Analysis:

Blood tests used in the diagnosis of diabetic ketoacidosis will measure: Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise. Ketone level. When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream. Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

VI. Management:

FLUID REPLACEMENT. You'll receive fluids either orally or through a vein (intravenously) until you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood. ELECTROLYTE REPLACEMENT. Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You'll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally. INSULIN THERAPY. Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you'll receive insulin therapy usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.
**As your body chemistry returns to normal, your doctor will consider what may have triggered the episode of diabetic ketoacidosis. Depending on the circumstances, you may need additional treatment. For example, if you have previously undiagnosed diabetes, your doctor will help you create a diabetes treatment plan. If your doctor suspects a bacterial infection, he or she may prescribe antibiotics. If a heart attack seems possible, your doctor may recommend further evaluation of your heart.**

I. Definition:
Diabetic hyperglycaemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes that involves extremely high blood sugar (glucose) levels without the presence of ketones. Ketones are by products of fat breakdown. Normally, the kidneys try to make up for high glucose levels in the blood by allowing the extra glucose to leave the body in the urine. If you do not drink enough fluids, or you drink fluids that contain sugar, the kidneys can

no longer get rid of the extra glucose. Glucose levels in the blood can become very high as a result. The blood then becomes much more concentrated than normal (hyperosmolarity).

**Hyperosmolarity is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances that normally cause water to move into the bloodstream. This draws the water out of the body's other organs, including the brain. Hyperosmolarity creates a cycle of increasing blood glucose levels and dehydration.**

II. Predisposing Factors:

A stressful event such as infection, heart attack, stroke, or recent surgery Congestive heart failure Impaired thirst Limited access to water (especially in patients with dementia or who are bedbound) Older age Poor kidney function Poor management of diabetes -- not following the treatment plan as directed Stopping insulin or other medications that lower glucose levels

III. Epidemiology:
a. PREVALENCE o HHNS: 0.5-1.0/1000 diabetics/year. o Hyperglycemic hyper osmolality is also present in 18% to 33% of cases of DKA. o It is 10% to 50% for HHNS b. MORTALITY o Mortality as high as 12-45%, increases with age and higher level of serum osmolality o No significant decrease in the incidence of HHNS or associated morbidity/mortality in the last 15-20 years c. ECONOMIC IMPACT o Results in more than 500,000 hospital days per year in the U.S. o Direct and indirect cost of 2.4 billion U.S. dollars annually o 1 in every 1000 hospital admissions d. AGE o Usually elderly, type II diabetics, frequently patients who are unable to maintain adequate fluid intake because of stroke, dementia, neglect, etc e. RACE Slightly more predominant in whites (45% non-whites).

IV. Clinical Signs and Symptoms:

Coma Confusion Convulsions Fever Increased thirst Increased urination (at the beginning of the syndrome) Lethargy Nausea Weakness

Weight loss Symptoms may get worse over a period of days or weeks. Other symptoms that may occur with this disease: Dysfunctional movement Loss of feeling or function of muscles Speech impairment

V. Laboratory Results and Analysis:

Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise. Blood acidity and osmolarity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body. . Glycosylated hemoglobin (A1C) a blood test that indicates your average blood sugar level for the past two to three months Kidney function. Testing the amount of blood urea nitrogen or creatinine in your blood

VI. Management:
- HHNS can be severe enough to require hospitalization, especially if occurring in a newly diagnosed diabetic. Several things may be done while you are in the hospital to monitor, test, and treat your condition. They include: Monitoring You will be checked often by the hospital staff. You may have fingers ticks to check your blood sugar regularly. This may be done as often as every hour.
You will learn how to check your blood sugar level in order to manage your diabetes when you go home.

A heart (cardiac) monitor may be used to keep track of your heartbeat. Your blood oxygen level may be monitored by a sensor that is attached to your finger or earlobe. Your fluid intake may be monitored closely by keeping track of everything you eat and drink and any IV fluids you receive. You may have a small tube (catheter) placed into your bladder through the urethra (the opening from the bladder to the outside of the body) to drain and measure urine from the bladder. Testing Testing may include: Blood tests (Hemoglobin A1c) to check your average blood sugar over the past 3 months. Blood tests to check for infections. Blood tests to test for mineral (sodium and potassium) levels Blood tests to check blood thickness and its ability to form clots Blood tests to check to see if your body is making insulin Blood, urine, or other tests to monitor how well your organs are functioning Urine tests to check for bacteria in your urine. Arterial blood gas (ABG): A blood test to measure the levels of oxygen and carbon dioxide in your blood. X-rays: Pictures of the inside of the chest to check for infection. Treatment The treatment for HHNS depends on the cause and how well you respond to treatment. The goal of treatment is to return your blood sugar to a normal level and keep it in a normal range. Treatment may include: You will have a small tube (IV catheter) inserted into a vein in your hand or arm. This will allow for medicine to be given directly into your blood and to give you fluids, if needed. Your provider may prescribe medicines to: o Keep your blood sugar controlled o Treat other medical problems that may have been caused by or made worse because of diabetes o Treat pain o Treat or prevent an infection o Prevent blood clots o Prevent side effects, such as nausea or constipation, from other treatments o Replace vitamins and minerals

You may receive oxygen through a small tube placed under your nose or through a mask placed over your face. If you develop blood clots, you may need surgery to remove them. You may need kidney dialysis to help filter your blood if your kidneys are not working properly. - Extreme HHNS requires gradual blood sugar lowering in a hospital setting. Milder HHNS can be treated mainly by reducing blood sugars using insulin. - Fluids such as water are required to replace the lost fluid and fix the dehydration.

I. Adult Fluid replacement in adults with DKA: In both DKA and HHNS the first goal is to restore circulating volume. In DKA this is done with an initial infusion of isotonic saline, 500 to 1000mL/hour over 1 to 2 hours (faster in hypovolemic shock). The usual fluid deficit in adults with DKA is 3 L to 5 L.
Approximate infusion rate in moderately dehydrated adults with DKA: a. 1st liter 1 Normal saline over the 1st 60 minutes. b. Next 2 liters of saline at 500 ml/hr (7ml/kg/hr) until dehydration resolves. c. Next 2 liters saline at 250 ml/hr x 4 hr. d. When the serum sodium rises to 145, switch to 0.45% NaCl ( normal saline). e. Blood glucose is expected to decrease by 75-100mg/dl/hr. When it reaches 250 f. mg/dL, change IV fluids to D5 NS & decrease rate to 100 to 200 ml/hr.In HHNS it averages 9 liters.

II. Child In children fluids are replaced more slowly because of the danger of exacerbating cerebral edema. Fluids are administered at a constant rate over the first 48 hours of treatment. Fluid administration is not front-endloaded as it is in adults.

The margin of error is smaller in children, so you have to calculate fluid requirements more precisely. Total fluid replacement equals the maintenance requirement plus the fluid deficit calculated as follows: Maintenance requirements: b. 100 mL/Kg for the 1st 10 Kg of weight c. +50 mL/Kg for the next 10 Kg of weight d. +20 mL/Kg for the remainder of the child weight e. Maintenance for 5 Kg child=500 mL/24 hr Fluid deficit: The percent dehydration estimated as in Table 2: Fluid replacement: The total fluid replacement (e.g. the maintenance requirements plus the calculated deficit) is infused evenly over a 48 hour period in order to reduce the risk of cerebral edema.
Example: If the patient were a 5 Kg child with 10% dehydration the replacement volume would be 500cc (daily Maintenance) + 250cc (total estimated deficit/2)=750cc each 24 hours for 2 days (48 hours).

I. Adult Fluid replacement in adults with hyperosmolar hyperglycemic syndrome (HHNS): 1. If the serum osmolality 320mOsmol, administer Normal saline, 1500cc/hour for the first hour, 1000cc/hour over the next 2 hours, then reduced to 500750cc/hour. When serum osmolality is less than 320mOsmol, 1 Normal saline should be used. 5% glucose is added to the electrolyte solution when the blood sugar reaches 250mg/dL. The average fluid deficit in HHNS is 9 liters. Hypotension requires faster initial infusion rates.

- HHNS is a severe condition that can cause other metabolic changes. Hospital care will test and address other chemical imbalances. - Once the main symptoms are alleviated, it is important to identify what caused the HHNS, so as to avoid it recurring. A common cause is that the patient is diabetic, but did not know they were. REFERENCES:

Huether and McCance (2005). Acute Complications of Diabetes Mellitus. Understanding Pathophysiology. 3rd ed. pp. 493-494. Philippines: Elsevier (Singapore) PTE LTD. Delaney, M. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Nonketotic Syndrome. Endocrinology and Metabolism Clinics 2000;29:683-705. Umpierrez GE, Khajavi M, Kitabchi AE: Review: Diabetic ketoacidosis and hyperglycemic nonketotic syndrome. Amer J Med Sci 1996;311(5):225-233. Treatment List for Hyperosmolar Hyperglycemic Nonketotic Syndrome. Retrieved last July 11, 2013 from http://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/treatments.htm#treatment_list Hyperosmolar Hyperglycemic Nonketotic State. Retrieved last July 11, 2013 from http://www.summitmedicalgroup.com/library/adult_care/ac-diabeteshhns_dx/ Hyperosmolar Hyperglycemic Nonketotic Syndrome Retrieved last July 11, 2013 from http://www.corephysicians.org/news-and-health-library/health-library/diabetes/diab3913/ Diabetic Ketoacidosis. Retrieved last July 7, 2013 from http://www.diabetes.org/living-withdiabetes/complications/ketoacidosis-dka.html Diabetic Ketoacidosis Epidemiology and Its Current Impact on Society. Retrieved last July 7, 2013 from http://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=prevention

Saint Mary's University

School of Health Sciences GRADUATE SCHOOL DEPARTMENT

Bayombong, Nueva Vizcaya

In Partial Fulfillment for the Requirements in

DIABETES NURSING
(

Diabetic emergencies)

Submitted To: Magdalena Juan, RN, MSN Instructor

Submitted by: Emily faye L. Turingan, rn Alma Vanessa M. Zapatero, rn KAtrina P. SERQUInA, RN Student

First Semester School year 2013-2014