Diabetic Ketoacidosis. Case Study By: Tiffany Peters 2/25/16

Transcription

1 Diabetic Ketoacidosis Case Study By: Tiffany Peters 2/25/16

2 Introduction L.D. is a 66 year old African-American male who was admitted to St. Francis Hospital on February 19, Upon examination in the Emergency Room, he was found to have altered mental status and hyperglycemia. He was transferred the ICU for critical care management of diabetic ketoacidosis, hyperkalemia, and acute kidney injury. He currently weighs kg and is 69 inches tall with a BMI of His ideal body weight for height is 72.7 kg. Due to a BMI >30 and 156% IBW, his body weight has been adjusted to 83 kg which will be used to calculate his calorie and protein needs. This patient was chosen for a case study review due to his complicated medical condition, disease process, and critical care state. This study begins at admission on February 19, 2016 and concludes on February 25, The focus of this study is diabetes disease process and complications from poorly controlled blood sugars requiring critical care management. Social History L.D. is a single man who has never been married and has no children. He lives with his brother and mother in a small home. He is his mother s primary care-taker along with his brother. Mr. D stated that he spends most of his time helping his mother and has let his own health become his last priority. He was a former lab technician, but has been on disability for a few years. His current health insurance helps to pay for his doctor visits and diabetes medication. L.D. has a Catholic background and relies on prayer to encourage him through this time. Normal Anatomy and Physiology of Organs Affected by Diabetes 2

3 Diabetes mellitus is a condition in which the body either has an absence of insulin or insulin is used inefficiently. 1 Without the effects of insulin, the body cannot regulate blood glucose levels effectively. Normally, the pancreas controls glucose in the bloodstream by producing the hormones insulin and glucagon. Insulin signals cells to take in glucose to be used as energy. With type 2 diabetes, the cells either resist insulin or the pancreas does not produce enough insulin to reduce blood glucose. This causes hyperglycemia which creates multiple complications such as neuropathy, decreased wound healing, and increased risk for cardiovascular and kidney disease. Diabetic ketoacidosis is a result of the lack of glucose as an energy source. The body turns to breaking down adipose tissue to use fat for energy. 2 These free fatty acids are turned into ketones. Ketones are very acidic and eventually lead to osmotic diuresis which causes metabolic acidosis. Past Medical History L.D. has a past medical history of type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His surgical history includes hip replacement. He denies any history of heart disease or any other significant medical history related to diabetes. There is no other record of previous visits or documentation of past medical history for this patient as this is his first admission to St. Francis Hospital. Present Medical Status and Treatment Diabetic ketoacidosis (DKA) is diagnosed when blood glucose levels are above 250 mg/dl along with a decreased blood ph, decreased sodium bicarbonate, and elevated serum ketones. 2 The higher the blood glucose and ketone levels, the more osmotic diuresis occurs resulting in electrolyte imbalances and possible dehydration. 1 Metabolic stability and resolving 3

4 fluid and electrolyte imbalance is the first priority for treating DKA. Without immediate attention, a diabetic coma or death may occur. 1 Upon admission, L.D. complained of dizziness, lightheadedness, and unsteady balance. He was assessed and reported to have altered mental status with severe hyperglycemia. He was also noted to have hyperkalemia and probable acute kidney injury. This is a likely occurrence in patients with diabetic ketoacidosis. Due to hyperglycemia, lack of insulin and L.D. s elevated serum sodium level, it is suspected he was having some impairment of the Na-K pump causing rhabdomyolysis. This is the most common cause of acute renal failure in these cases. 3 The patient was immediately admitted to the medical intensive care unit for management of these conditions. He was started on vigorous IV fluids to treat hypovolemia after he was found to have erythrocytosis. Insulin infusion was also started right away to correct blood glucose levels. The intensivist chose to give the patient Kayexalate plus insulin, glucose, and sodium bicarbonate to treat hyperkalemia instead of treating the potassium directly because the elevated level was most likely due to the acidosis. During metabolic acidosis, the buildup of hydrogen ions cause a decrease in ph which elevates serum potassium levels. Once the acidosis is corrected, potassium levels will return to normal. 1 Within 24 hours, Mr. D s condition had stabilized. The hyperkalemia and acute kidney injury was resolved and blood glucose levels had dropped. Aggressive IV fluid was continued given his initial volume depletion. The intensivist transitioned him to a subcutaneous insulin regimen due to the patient having never been on insulin therapy and his extreme uncontrolled diabetes. It is just as effective as intravenous insulin, and is beneficial because L.D. will need to continue this regimen as part of his diabetes control. 2 However, once starting an oral diet, he 4

5 had a recurrence of severe hyperglycemia and insulin therapy was adjusted again. Readjustments are sometimes needed until the right dosing has been reached. It was also noted that L.D. had developed thrombocytopenia of unclear etiology. He continued to be monitored for this condition. On February 22, L.D. was moved out of ICU to a regular hospital room. At this time, the patient felt very weak; however, the acidosis had resolved. He was consulted to an Endocrinologist and was seen by the diabetes educator and dietitian intern for diabetes education and assessment. Thrombocytopenia remained an issue, but the patient was clearly not septic nor had he been given any heparin medication to cause this issue. Blood pressure was being monitored and addressed with Diovan and Norvasc. Due to thrombocytopenia, the patient was not receiving any blood thinner medication. He was encouraged to ambulate for deep vein thrombosis prophylaxis. He had several bouts of nausea and emesis on day four of his hospital stay. This was most likely due to the hyperosmolar state brought on by severe hyperglycemia. By the next day, L.D. was feeling much better with no complaints of gastrointestinal distress. He continued on Levemir and Novolog to control his diabetes. He was educated by a certified diabetes educator on how to give himself insulin injections. By this time, the thrombocytopenia was improving, but he was monitored for signs and symptoms of bleeding for the next 24 hours. He continued to improve and all medical conditions were resolved. The patient was discharged on February 25, Labs Upon presentation to the ER, Mr. D. had a serum glucose of 1033 mg/dl and serum potassium of 7.3 mg/dl. Before moving him to the floor, the patient was given insulin to 5

6 address his elevated blood sugars. His admission and final lab results are listed in the table below. Medications Admission lab values 2/19/16 Final lab values 2/25/16 Normal lab values Sodium Potassium Chloride TCO Glucose BUN Creatinine Calcium Hemoglobin Hematocrit Anion gap Total Protein Total Bili ALT/SGPT AST/SGOT Albumin Alk Phos Hemoglobin A1C Medication Purpose Drug/Nutrient Interaction Possible Side Effects PRN: Normal Saline Flush Potassium Chloride Dextrose (50%) To clear medications from the port to make sure the drug was delivered fully. to prevent or to treat low blood levels of K+ (hypokalemia) Used for dehydration and/or to control blood sugars May alter how other medications work Not to be taken while using salt substitutes. May lower serum sodium and increase serum potassium Possible allergic reaction. Symptoms include rash, itching/swelling, severe dizziness, and trouble breathing. May cause GI irritation, nausea, vomiting, abdominal pain, diarrhea, or flatulence. Hyperglycemia, edema 6

7 Magnesium Sulfate laxative Take fiber, folate, or iron supplement separately by at least 2 hours. Do not take with increased fiber. Magnesium Carbonate To treat low serum Take with a meal to Magox Glucagon Trandate Zofran ROUTINE: Kionex magnesium Magnesium supplement or used to treat acid indigestion, or heartburn; also has laxative effect Used to treat hypoglycemia Used to treat hypertension Antiemetic, antinauseant Used to treat hyperkalemia prevent upset stomach Take fiber, folate, or iron supplement separately by at least 2 hours. Do not take with increased fiber or high oxalate or phytate foods Diabetic meal plan to balance glucagon, insulin, and carbohydrate intake Avoid natural licorice N/A Decrease high potassium foods and take MVI separately by 2 hrs Limit caffeine/xanthine Proventil Used as a bronchodilator Novolog Fast acting insulin Diabetic meal plan to to lower blood balance carbohydrate with glucose insulin Diovan Used to treat type Do not take with potassium II diabetic supplement. nephropathy Levemir Long acting insulin Diabetic meal plan to to lower blood balance carbohydrate with glucose insulin Norvasc Used to treat Avoid natural licorice hypertension Dulcolax Laxative Do not take within 1 hour of milk/milk products Apresoline Used to treat hypertension Food increases bioavailability. Avoid natural licorice May cause nausea, vomiting, cramps, or diarrhea. May cause nausea, vomiting, or diarrhea May cause nausea, vomiting, or diarrhea May cause nausea, vomiting, dizziness, irregular heartbeat, or loss of appetite May cause taste changes, nausea/vomiting, or dyspepsia May cause dry mouth, abdominal pain, constipation, or diarrhea May cause cough, chest pain, shortness of breath, or abdominal pain May cause nausea, vomiting, dyspepsia, or diarrhea May cause weight gain or hypoglycemia May cause dyspepsia, abdominal pain, or diarrhea May cause weight gain or hypoglycemia May cause dysphagia, nausea, or cramps May cause nausea, belching, abdominal cramps, or diarrhea May cause dry mouth, unpleasant taste, nausea, vomiting, GI distress, diarrhea, or constipation 7

8 Treatment The initial treatment for diabetic ketoacidosis is IV fluids and insulin. It is imperative to also correct electrolyte balance. IV fluids of 0.9% normal saline was started right away for L.D. and continued vigorously until volume depletion was stabilized. There have been several studies discussing the use of Plasma-Lyte as an alternative to 0.9% normal saline in volume repletion for patients with diabetic ketoacidosis. According to Stowe, 4 patients recover faster when using Plasma-Lyte and also tend to have lower serum chloride and higher bicarbonate levels. This is because it contains organic acid buffers that are very similar to plasma. It contains a lower concentration of chloride, which when compared to normal saline, is less likely to lead to hyperchloremia. Plasma-Lyte was also found to improve mean arterial pressure and urine output more rapidly. Normal saline has been proven to be safe; however, Plasma-Lyte seems to be an extremely effective alternative. More evidence is needed to determine safety for regular use in the intensive care unit. 4 To treat L.D. s extreme hyperglycemia, he was started on insulin therapy. Normally, a patient would be put on an IV insulin. However, the intensivist felt it would be more beneficial to use subcutaneous insulin to correct his glucose levels. Mr. D. will need to use insulin for an extended amount of time to get his diabetes under control, therefore, starting him on injections would help get the correct dosing figured out for long term use. According to Westerburg, 2 using subcutaneous insulin was just as effective on clinical outcomes as using intravenous insulin. A rapid acting insulin such as Novolog or Humulin is administered at 0.3 units per kg every one to two hours. Adjustments can be made as needed. L.D. was also placed on Levemir which is a long acting insulin. This is used as a background insulin which helps 8

9 reduce extreme peaks and valleys of glucose levels. He will continue on this regimen to control his diabetes. Medical Nutrition Therapy L.D. stated his diet is varied and irregular. Taking care of his mom is his top priority and her schedule often dictates his eating patterns. In the morning, he is busy getting his mother ready and fixing her meals. He mentioned he skips lunch often. L.D mostly eats at home, but will occasionally eat out. He cooks and prepares most of the meals for his family. He enjoys afternoon snacks, however, they consist of mostly desserts and sweets. An analysis of foods he would normally eat is listed in the table below. Breakfast Carbs (g) Protein (g) Fat (g) Sodium (mg) Calories 1 cup cereal ½ cup fat free milk oz glass orange juice slice toast Tbs jam Lunch Turkey sandwich with mayo, lettuce, and cheese 8 oz ice tea Snack 1 Donut oz Coke Dinner 1 grilled chicken breast (5 oz) ½ cup summer squash ¾ cup mashed potatoes Bedtime snack 6 peanut butter sandwich crackers Once L.D. was stabilized and transferred out of the intensive care unit to a regular hospital room, he was placed on a 2000 calorie diabetic diet. He eats % of his meals 9

10 which would provide approximately calories and grams of protein per day. At kcal/kg and g/kg protein using his adjusted body weight for weight maintenance, L.D. s needs are kcal and grams protein. This diet is designed to control carbohydrate intake for patients who have diabetes. Each meal is served on a strict schedule to maintain consistent intake. It is very important for patients to eat every 4-5 hours to regulate their blood glucose levels and for proper dosing of medications and insulin. On this diet, Mr. D. was given 5 carbohydrate servings every meal which is equivalent to 75 grams per meal. This also gives a daily total of 225 grams carbohydrate and is equal to 45% of daily caloric intake. The patient was compliant with his diet and stated he enjoyed the food. He remained on the ADA diet throughout his stay at the hospital. Along with medication, the controlled carbohydrates brought down his blood glucose levels from 304 to 153 mg/dl. This is a significant improvement considering his hemoglobin A1C of The major nutrition related problem for this patient is maintaining a scheduled eating pattern at home. From his diet history, it is very obvious that he does not eat consistently and skips many meals. He has poor self-monitoring skills which is why changing his eating habits will play a major role in overall control of his disease. Clinical studies have confirmed that following the recommendations for the nutrition therapy of diabetes can decrease A1C levels in 3-6 months. 5 In Mr. D s case, there is no need for alternative feeding methods. If his intake becomes compromised, Glucerna Shakes may be added to his diet in order to supplement calories and protein. In order for success upon discharge, L.D. should be referred by his doctor to see an outpatient diabetes educator for additional education and careful monitoring of medications, diet, and glucose control. Before discharge, L.D. was very motivated to start taking 10

11 better care of his disease. He was encouraged by the information which empowers him to make better choices concerning his diet. Prognosis L.D. s current prognosis is very good. His diabetic ketoacidosis has resolved and he was feeling much better at time of discharge. For this patient, the biggest challenge is ahead of him. Because of his poor self-monitoring skills and compliance with diabetes control, L.D. will need to make some considerable changes to his normal daily routine. In order to decrease his hemoglobin A1C and prevent more complications, it is imperative for him to check his blood glucose levels every day, take his medications and insulin, and be consistent and compliant with the American Diabetes Association diet. His success with this will be greatly strengthened by seeing an outpatient diabetes educator. His main goal is to manage his disease at home to prevent diabetic ketoacidosis and any other complications from happening in the future. Summary & Conclusion During this study, I was able to see the full blown effects of uncontrolled diabetes. This patient had the highest blood glucose levels I have ever seen in a patient. Researching diabetic ketoacidosis opened my eyes to how the body reacts to insulin and hyperglycemia. It gave me a greater appreciation for the body s natural way of compensating for the lack of human responsibility. As always, I enjoyed interacting with this patient and asking deeper questions to truly get an overall picture of his life outside of the hospital. This allowed me to pinpoint specific areas in his diet that needed work. I felt very satisfied after educating this patient because I felt he really wants to make a change, and I made a difference in helping him achieve it. 11

12 References 1. Nelms, M. Sucher, K., Lacey, K., and Roth, S.L. Nutrition Therapy & Pathophysiology. 2 nd ed. Brooks/Cole Cengage Learning, Belmont, CA; Westerberg, D. P. (2013). Diabetic ketoacidosis: evaluation and treatment. American family physician, 87(5). 3. Deng, D., Xia, L., Chen, M., Xu, M., Wang, Y., & Wang, C. (2015). A case of fulminant type 1 diabetes associated with acute renal failure. Neuro endocrinology letters, 36(2), Stowe, M. (2012) Plasma-Lyte vs. Normal Saline: Preventing Hyperchloremic Acidosis in Fluid Resuscitation for Diabetic Ketoacidosis. School of Physician Assistant Studies American Diabetes Association. (2012). Standards of medical care in diabetes Diabetes care, 35, S11. 12