DIABETES EMERGENCIES. Mary Bruskewitz, MS, APN, RN, BC-ADM Clinical Nurse Specialist - Diabetes. 12/1/2014 UWHealth 1

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1 DIABETES EMERGENCIES Mary Bruskewitz, MS, APN, RN, BC-ADM Clinical Nurse Specialist - Diabetes 12/1/2014 UWHealth 1

2 Diabetes Emergencies Review diabetes medications see handouts Review A1c Review common lab tests used in diagnosing types of DM Acute Hypoglycemia DKA HHS Case study 12/1/2014 UWHealth 2

3 Oral Medications Biganuides Metformin decreases amount of glucose produced by the liver Sulfonyureas Glipizide, Glimiperide, Glyburide Pancreas releases more insulin Thiazolidinediones (TZD) Actos Helps muscles and cells use insulin better Meglitinides Starlix, Prandin Pancreas releases more insulin Alpha Glucosidase Inhibitors Acarbose, Miglitol Blocks the breakdown of starches DPP-4 Januvia, Onglyza, Tradjenta Decreases postprandial glucose by inhibiting DPP-4 via digestion process, signal to pancreas 312/1/2014 UWHealth Insulin & non-insulin Injectable Short-action (bolus) Novolog, Humalog, Apidra Covers meal carbohydrates Slower-action for meals (bolus) Regular Intermediate action (basal) NPH, Levemir Long-action (basal) Lantus Incretin- Mimetics/GLP-1 analogue Byetta (exenatide) Byduron (exenatide-extended release) Victoza, Tanzeum, Trulicity improves insulin/modulates postprandial glucose metabolism, signal to pancreas, (liver, stomach, pancreas, brain *byetta only Insulin Sensitizer Symlin 1 st phase

4 Normal Glucose Metabolism Physiology 1. Food enters stomach + signal to pancreas that food is coming phase 1 4. Pancreas releases insulinphase 2 5. Insulin unlocks receptors 2. Food is converted into glucose 3. Glucose enters bloodstream 6. Glucose enters cell & available for energy 412/1/2014 UWHealth

5 A1c Measures the amount of sugar on the hemoglobin molecule of the RBC Under 5.5% normal, % prediabetes, Above 6.5% diabetes 12/1/2014 UWHealth 5

6 Hypoglycemia Glucose under 70 mg/dl Individualized by presence, decrease or absence of symptoms Type 1: 1-2 episodes/wk (10-25% severe requiring assistance) Type 2: unknown # Under-reported Ignored by patients and providers T1, goal for many patients T2, goal is high enough BG to prevent 12/1/2014 UWHealth 6

7 Hypoglycemia Unawareness If no symptoms, then not hypoglycemic WRONG! Afraid to keep BG normal (patients & medical staff) Providers fear hypoglycemia Increase risk of losing initial warning signs if long term DM or frequent hypoglycemia Glucose drops lower < 20 before warning signs Lack of glucagon response A decrease or lack of epinephrine response A decrease & delay in all counter-regulatory responses 12/1/2014 UWHealth 7

8 Treatment Step 1 Simple carbohydrate 15 gms Any fruit juice, 4-6 oz Milk, 8 12 oz Regular Soda,4-6 oz 3-4 Glucose tabs/gel, total 15 gms 3 pieces of hard candy 1 glucose gel tube Wait min Recheck BG & repeat treatment until BG > 80 mg/dl, driving > 130 Tendency to panic, normal Tendency to over eat, normal Step 2 Complex carbohydrate Milk Bread or crackers Protein Usual meal w/ above Step 3 Glucagon injection 911 Education 12/1/2014 UWHealth 8

9 Causes Too little food, too much insulin &/or oral medication for the circumstances Exercise with no reserve BG Compromised defenses - counter regulatory hormones (glucagon, epinephrine, cortisol, growth hormone) Management of diabetes (insulin, exercise, oral medication, food) Lack of education Iatrogenic Sliding scale NPO without adjusting DM medications Missed snacks Insulin at wrong time Discharge DM orders w/o reviewing admission DM orders Not well understood by professionals 12/1/2014 UWHealth 9

10 Other Factors MVA MI Treatment of rebound hyperglycemia (glucagon, epinephrine, cortisol, growth hormone) Poor follow-up care by patient & health care Lack of education Misunderstanding of target A1c to prevent diabetes complications BG goal set & agreed by patient, family & professionals 12/1/2014 UWHealth 10

11 Insulin Pumps/Sensors in DM Emergencies Leave the pump alone If pump is in the way with traume, remove Leave the sensor alone unless in the way Alert ER Provide another source of insulin, if pump is removed Pump & sensor are not damaged in CPR 12/1/2014 UWHealth 11

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13 Key Elements Hyperglycemia Insulin Dehydration Electrolyte imbalance DKA vs HHS not well understood by many Resulting complications Emergent treatment 12/1/2014 UWHealth 13

14 DKA Statistics DKA is the most significant cause of death in childhood diabetes % mortality due to DKA in the United States, majority from cerebral edema One out of every two health care dollars spent on adult patients with T1 diabetes is for DKA-ER, drugs Not limited to T1, can be present in T2 Severity of DKA differs from mild managed at home to critical, life threatening % of patients with diabetes experience DKA per year 12/1/2014 UWHealth 14

15 Diabetic Ketoacidosis (DKA) Relative or absolute deficiency of insulin A life-threatening but reversible complication characterized by severe disturbances in carbohydrate, protein, fat and electrolyte metabolism Life threatening in the young & old Mild forms can be managed at home, ambulatory or ED if well controlled & in contact with diabetes specialist 12/1/2014 UWHealth 15

16 Physiology of DKA Increased blood glucose -lack of insulin -gluconeogenisis by the liver Ketogenesis (fat metabolism for energy) Acidosis from increased circulation of acetoacetic acid and 3-Bhydroxybutyric acid, byproducts of fatty acid breakdown 12/1/2014 UWHealth 16

17 Pathogenesis of DKA & HHS 12/1/2014 UWHealth 17

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21 Biochemistry Low insulin levels combined with increased levels of catecholamine, cortisol, and growth hormone activate hormone-sensitive lipase Lipase causes the breakdown of triglycerides and release of FFA. FFA are taken up by the liver, converted to ketones & released into circulation. Glucagon activates enzymes allowing FFAs to cross the mitochondrial membrane After crossing the membrane, process reversed in the synthesis of ketones, Beta hydroxybutyric acid and acetoacetic acid. These two acids responsible for the acidosis in DKA Presence of adequate insulin prevents this process 12/1/2014 UWHealth 21

22 DKA vs HHS Acidosis DKA Younger or Older Dehydration 50% known T1 DM, Onset in hours Alert coma (20%) Mild treated at home or ED 1-10% elevated WBC Sick days management usual cause in known T1 HHS Normal or slight acidosis Older or elderly Severe dehydration T2 Slow onset, days to weeks Coma is common 90% underlying cardiac or renal 10-50% increase WBC, a predictor of outcome 12/1/2014 UWHealth 22

23 Role of Counter-regulatory Hormones in DKA/HHS Epinephrine, Glucagon, Growth Hormone, and Cortisol Inhibit insulin-mediated glucose uptake by muscle Activate glycogenolysis (glycogen breakdown) and gluconeogenisis (glucose production in liver) Activate lipolysis Inhibit residual insulin secretion 12/1/2014 UWHealth 23

24 Causes of DKA No insulin Infection Patient not following treatment plan New-onset type 1 diabetes Glucocorticoid use Sepsis-acute stress of MI or sepsis increase insulin needs Pancreatits Alcohol Cocaine Burns Stroke Sick Days 12/1/2014 UWHealth 24

25 Clinical Presentation Polyuria (5-7 liters) Polydipsia Anorexia illeus Abdominal pain Fatigue Nausea and vomiting Appetite loss Difficulty Breathing 12/1/2014 UWHealth 25

26 Physical Examination Initial assessment Hyperventilation (metabolic acidosis induces hyperventilation) ketones being breathed out Skin (dehydration) Breath (fruity odor of ketones) Mental stupor that may progress to coma Decreased blood pressure Tachycardia Confusion Cardiac arrthymias 12/1/2014 UWHealth 26

27 Labs Elevated leukocyte count (due to stress and dehydration) Glucose >300mg/dL usually. Serum ph <7.3 Hypokalemia - from initial diuresis Hypophosphatemia- from respiratory depression and cardiac dysfunction Hypoxemia Anion Gap- The difference between the sum of cations and anions found in plasma or serum (Na+K)-(Cl + HCO3-) Serum Osmolality- The concentration of particles dissolved in a fluid 2xNa meq/l+(glucose mg/dl/18)+(bun mg/dl/2.8) O2 Saturation 12/1/2014 UWHealth 27

28 Labs DKA BG > 250 (> 900, coma) Ketones present NA low or normal Potassium elevated or normal Bicarb < mg/dl Anion Gap > 10 meg/l Osmolality - varies ph < BUN HHS BG > 600 Absent or small ketones NA normal, low, elevated Potassium normal, low, elevated Bicarb > 18 meg/l Anion Gap normal (10-12) Osmolality > 320, high as 380 ph > 7.3 BUN elevated 12/1/2014 UWHealth 28

29 Diagnostic Criteria for DKA Plasma glucose (mg/dl) Mild Moderate Severe >250 >250 >250 Arterial ph Serum bicarbonate (meq/l) <15 <10 Urine ketones Serum ketones Anion gap >10 >12 >12 Alteration in sensorium Alert Alert/drowsy Stupor/coma 12/1/2014 UWHealth 29

30 Diagnostic Test Findings for DKA Elevated serum glucose Positive serum ketones Positive urine ketones Decreased serum sodium concentration Increased serum potassium initially, then decreased because of increased diuresis and reversal of acidosis and insulin administration Metabolic acidosis evident on arterial blood gas analysis Elevated hemoglobin and hematocrit because of diuresis and dehydration Lowered hemodynamic pressures Dysrhythmias on electrocardiogram associated with potassium imbalances 12/1/2014 UWHealth 30

31 DKA 6 L dehydration Na: 7 to10 Cl : 3 to 5 K: 3 to 5 PO4: 5 to 7 Mg: 1 to 2 Ca: 1 to 2 HHS 9 L dehydration NA: 5 to 13 Cl: 5 to 15 K: 4 to 6 PO4: 3 to 7 Mg: 1-2 Ca+: /1/2014 UWHealth 31

32 Effects of Acidosis and Alkalosis on Intracellular:Extracellular Ratio of K + For every 0.1 in serum ph, serum K + will by 0.6, and vice versa. 12/1/2014 UWHealth 32

33 Complications of DKA Acute Respiratory Distress Syndrome (ARDS)-pulmonary edema Ischemia- hypotension MI-Hyperkalemia, decreased blood pressure Hypertriglyceridemia- breaking down fat for energy Central nervous system disturbances Renal Failure- glucose and ketones in kidney Pre-renal azotemia- high nitrogen waste in blood stream b/c of low blood flow to kidneys, urine volume lower (elevated creatinine and urea) pt had high creatinine on day 1 only Electrolyte Imbalance (Na, K, Mg, Ca, P) Aspiration pneumonia Shock Acute tubular necrosis (HHS) Vascular thrombosis (HHS) Cerebral edema (reversal of dehydration & BG too fast) Clotting problems (HHS) Gastric stasis (HHS) Pancreatitis (HHS) 12/1/2014 UWHealth 33

34 DKA s Effect on Organs-Kidneys Renal Function is impaired Impaired glucose filtration at the renal corpuscle and reabsorbed by the tubules. Urine ketones & glucose can damage renal nephrons Maximum glucose reabsorptive capacity is exceeded Ketones are lost in the urine The unreabsorbed solutes (ketones and glucose) cause an osmotic diuresis (increased urine flow as a result of increased solute excretion) Leading to dehydration and electrolyte deficiency 12/1/2014 UWHealth 34

35 DKA s Effect on Organs-Brain Increased plasma hydrogen-ion concentration caused by the accumulation and dissociation of ketones Cerebral edema if BG & dehydration are corrected too fast Can lead to coma or death 12/1/2014 UWHealth 35

36 Treatment Goal: Normalize metabolic state with insulin, electrolyte, and fluid replacement w/o complications Continuous monitoring to detect cardiac arrhythmias Physical Examination Patency of airway Mental status Cardiovascular and renal status State of hydration Strict monitoring of I/Os IV insulin 12/1/2014 UWHealth 36

37 Complications with Treatment Hypokalemia Hypoglycemia Pulmonary Edema Vascular Thrombosis Cerebral Edema MI-Hyperkalemia, decreased blood pressure Central nervous system disturbances Renal Failure- glucose and ketones in kidney 12/1/2014 UWHealth 37

38 Cerebral Edema Rehydrate and drop BG levels too quickly causes change in osmolality causing water to be drawn into the brain. Children are at higher risk of cerebral edema because dehydration occurs quickly Assess serum osmolality and mental status regularly during rehydration 12/1/2014 UWHealth 38

39 Cerebral Edema in DKA 6977 DKA cases 61 (0.8%) with cerebral edema Died 13 Recovered without severe neurological complication 35 Recovered with severe neurological complication 13 Glaser, et al 12/1/2014 UWHealth 39

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41 Clinical Assessment DKA Significant weight loss N & V common Abdominal pain Alcohol/drug use Absolute or deficient insulin Tachycardia Low or normal BP Kussmaul breathing HHS Minimal weight loss N & V not present unless underlying cause Some insulin present Pancreatitis, dialysis, GI bleed, sepsis, CVA, hypothermia, MI, ARF Low or normal BP, dependent on underlying cause EKG arrhythmias 12/1/2014 UWHealth 41

42 Treatment Isotonic fluid DKA (5-6L) vs. HHS (8-12L) Concern with fluid overload in HHS, age, underlying cause Cardiac monitoring (K+ changes) Insulin Drips (smaller doses in DKA) Treat underlying cause Admission/ICU (HHS -ICU common) 12/1/2014 UWHealth 42

43 Complications Hypokalemia with related arrhythmia Aspiration pneumonia Acute tubular necrosis (HHS) Vascular thrombosis (HHS) Cerebral edema (reversal of dehydration & BG too fast) Clotting problems (HHS) Gastric stasis (HHS) Pancreatitis (HHS) 12/1/2014 UWHealth 43

44 Prevention Sick day management of glucose When to notify health care team Blood glucose goals and use of supplemental short-acting insulin during illness Initiation of an easily digestible liquid diet containing carbohydrates and salt. Pump therapy when sick Education Never discontinuing insulin When to check glucose and ketones when sick or when blood glucose is higher than 240mg/dL 2x in a row 12/1/2014 UWHealth 44

45 In Summary DKA is a complete lack of insulin DKA can result in death Continuous monitoring of labs (especially K+) and I/Os is crucial to pt. survival in DKA HHS, critical in diagnosing & treatment HHS > DKA mortality Education on how to detect a DKA episode can prevent occurrence 12/1/2014 UWHealth 45

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47 Background PMH: Kidney & pancreas tx (2002), CAD, HTN, hyperlipidemia Chronic hepatitis likely due to medications Osteoporosis Does not smoke or drink alcohol Autonomic neuropathy (gastroparesis, urinary retention) 55 age, T1 Diabetic 1978 Known previous DKA episode (6/2002) July-possible cardiac necrosis >10 troponin Poor short-term memory (many DKA episodes) Questionable understanding & use of all medications Insulin forgets to take, uncertain dosages, difference Lives with elderly mother 12/1/2014 UWHealth 47

48 Commumnity Hospital Dx: Unspecified septicemia (leukocytes elevated) with probable DKA, probable upper GI bleed, probable MI ph: unknown, error BG: >1000 mg/dl BP: 116/82, but decreased to 108/45 during med flight HR:117 Troponin: 8 Intubated Treated for volume depletion with 5 liters normal saline NG tube placed with persistent bloody output Insulin drip started 12/1/2014 UWHealth 48

49 Day 1 Pt. admitted to UW-Hospital TLC via Med Flight after being found unconscious laying in coffee ground emesis with 2-d h/o N/V Dx: DKA Complications: multiorgan system failure, possible upper GI hemorrhage, probable MI, respiratory failure, hypotensive, possible pneumonia (treated with broad-spectrum IV), ARF significant w/ hx transplant Ht:6 1 Wt: 95.5 kg (IBW: 83.6 kg) HR: 108 BP: 108/82 Troponin: /1/2014 UWHealth 49

50 Day 1, cont. No anticoagulant given because of possible GI bleed O2 saturation: 98% Serum Osmolality: 324mOsm/L (normal mosm/l) ph: 7.40 Anion gap: 26 Given IV K+ with continued insulin drip BG monitoring every 1-2 hrs 12/1/2014 UWHealth 50

51 Day 2 Pt. screened at high nutritional risk Cardiology noted severe reduction in systolic function of LV Dx: Infarction. Nephrology recommends using D5W R/O sepsis vs elevated WBC due to DKA Additional dx of prerenal azotemia and anemia Patient is diagnosed with stage II CKD DKA resolving, Anion gap 11 12/1/2014 UWHealth 51

52 Day 2, cont. Troponin: 89.7ng/mL Given metoprolol (beta-blocker) to relieve chest pain HTN controlled, 106/82 HR: 81 & tachycardia Ejection Fraction: 25% Mg supplement Began iron supplement 12/1/2014 UWHealth 52

53 Day 3 HR: BP: /70-80 Extubated Remove NG tube GFR: 50-55% Coronary angiography Bronchoscopy 12/1/2014 UWHealth 53

54 Continued ICU Day 4 Reintubated - O2 saturation was down to 90% Day 5 O2 improved Pulmonary Edema worsening, started on diuretics Day 6 Glucose levels stable, average 120mg/dL BUT Frequent hypoglycemia/hyperglycemia Extubated 12/1/2014 UWHealth 54

55 Day 9 LV systolic function has improved Transferred out of ICU Glargine & Aspart started Check bg 6x/day Cardiac with consistent CHO diet Nutritional Reassessment ARF resolving 12/1/2014 UWHealth 55

56 Day 10 Primary Dx: unspecified septicemia Dx: DKA, Type 1 Diabetes, MI, Possible upper GI bleed, HTN, Heart Failure, ARF (resolving), Candidate for renal tx Prescribed plavix, lipitor, and aspirin for CAD Unstable blood glucose levels at discharge Ejection fraction 55% Plan to be discharged to a nursing home for better monitoring of hyperglycemia A1c: 8.5% 12/1/2014 UWHealth 56

57 Day 10, cont. Memory assessment to follow Frequent hypoglycemia causing cell death Adjust glargine & aspart for hyperglycemia/hypoglycemia 12/1/2014 UWHealth 57

58 Discharge Medications Aspirin, lipitor, plavix, Nitroglycerine (relaxing the blood vessels to the heart, so the blood flow and oxygen supply to the heart is increased) Fish oil, glargine, aspart, insulin Mycophenolate & Tacrolimus (prevent the body from rejecting a transplanted organ) Toprol (reduce hypertension), lisinopril (ACE inhibitors for kidneys) Alendronate (osteoporosis) Duloxetine (to relieve nerve pain peripherl neuropathy) Omeprazole (GERD), Lasix Methadone (narcotic pain reliever) Multivitamin, vitamin B12, iron sulfate, calcium, vitamin D, Doxycycline 12/1/2014 UWHealth 58

59 Summary Could MI lead to all other complications with the counter-regulatory hormones, infection, transplant medications, poor care BUN and creatinine often abnormal after Tx because of meds Multiple organ failure How much did chronic hyperglycemia play a role? Delayed wound healing Increased incidence of infections Changes in mental status Nutritional deficit increased LOS Increased ICU 12/1/2014 UWHealth 59

60 Summary of Labs 12/1/2014 UWHealth 60

61 Labs for Case Study Day Glucose ( mg/dl) BUN (7-20mg/dL) Creatinine ( mmol/l) Sodium ( mmol/l) Potassium ( mmol/l) Chloride ( mmol/l) CO2 (22-32 mmol/l) Anion gap (7-14) Troponin (0-0.3 ng/ml) /1/2014 UWHealth 61 7

62 Labs, cont. Day Calcium ( mmol/l) Magnesium ( mmol/l) Phosphorus ( mmol/l) Hemoglobin ( g/dl) Hematocrit (40-52 ml/dl) Oxygen Saturation /1/2014 UWHealth 62