What should a nurse do during an episode of diabetic ketoacidosis?
While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick.
Can we manage diabetic ketoacidosis in adults in the emergency department?
Dr R D Hardern, Department of Accident and Emergency Medicine, The General Infirmary, Great George Street, Leeds LS1 3EX, UK; [email protected] The authors propose a regimen for managing diabetic ketoacidosis in adults based on available evidence and their experince in the emergency department.
What should be included in patient education about diabetic ketoacidosis (DKA)?
It is vital that patients who develop DKA receive, before discharge from hospital, education about how to manage their insulin in the event of intercurrent illness. This information should have been provided previously to all patients treated with insulin.
Which fluids are used in the initial management of diabetic ketoacidosis (DKA)?
Physiological (0.9%) saline is the fluid usually used in the initial management of DKA though no formal comparisons with 0.45% saline or Ringer’s solution have been reported.
What is the first treatment for diabetic ketoacidosis?
The initial priority in the treatment of diabetic ketoacidosis is the restoration of extra-cellular fluid volume through the intravenous administration of a normal saline (0.9 percent sodium chloride) solution.
How do you manage emergency ketoacidosis?
When treating patients with DKA, the following points must be considered and closely monitored:Correction of fluid loss with intravenous fluids.Correction of hyperglycemia with insulin.Correction of electrolyte disturbances, particularly potassium loss.Correction of acid-base balance.More items...•
What should a nurse do for DKA?
Nursing Interventions of DKA Teach patient early signs and when to seek treatment: Monitor glucose and ketones during illness every 4 hours, especially if dealing with illness/infection. If vomiting and cannot eat food or drink liquids notify doctor (if can tolerate drink liquids every hour)
Is diabetic ketoacidosis a medical emergency?
Elevated ketones are a sign of DKA, which is a medical emergency and needs to be treated right away. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. DKA is most common among people with type 1 diabetes. People with type 2 diabetes can also develop DKA.
How is emergency hyperglycemia treated?
Emergency treatment for severe hyperglycemia Treatment usually includes: Fluid replacement. You'll receive fluids — usually through a vein (intravenously) — until you're rehydrated. The fluids replace those you've lost through excessive urination, as well as help dilute the excess sugar in your blood.
What is DKA in diabetes?
Diabetic ketoacidosis (DKA) is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Elements of management include making the appropriate diagnosis using current laboratory tools and clinical criteria and coordinating fluid resuscitation, insulin therapy, and electrolyte replacement through feedback obtained from timely patient monitoring and knowledge of resolution criteria. In addition, awareness of special populations such as patients with renal disease presenting with DKA is important. During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. DKA prevention strategies including patient and provider education are important. This review aims to provide a brief overview of DKA from its pathophysiology to clinical presentation with in depth focus on up-to-date therapeutic management.
What are the therapeutic goals of DKA?
The therapeutic goals of DKA management include optimization of 1) volume status; 2) hyperglycemia and ketoacidosis; 3) electrolyte abnormalities; and 4) potential precipitating factors. The majority of patients with DKA present to the emergency room. Therefore, emergency physicians should initiate the management of hyperglycemic crisis while a physical examination is performed, basic metabolic parameters are obtained, and final diagnosis is made. Several important steps should be followed in the early stages of DKA management: 1 collect blood for metabolic profile before initiation of intravenous fluids; 2 infuse 1 L of 0.9% sodium chloride over 1 hour after drawing initial blood samples; 3 ensure potassium level of >3.3 mEq/L before initiation of insulin therapy (supplement potassium intravenously if needed); 4 initiate insulin therapy only when steps 1–3 are executed.
How does volume resuscitation help with hyperglycemia?
Intravascular and extravascular volume resuscitation will decrease hyperglycemia by stimulating osmotic diuresis if renal function is not severely compromised and enhance peripheral action of insulin (insulin effects on glucose transport are decreased by hyperglycemia and hyperosmolarity). When glucose levels fall below 200–250 mg/dL, intravenous fluids should be switched to dextrose-containing 0.45% NaCl solution to prevent hypoglycemia, and/or insulin infusion rate should be decreased. Special considerations should be given to patients with congestive heart failure and chronic kidney disease. These patients tend to retain fluids; therefore, caution should be exercised during volume resuscitation in these patient groups. Urine output monitoring is an important step in patients with hyperglycemic crises.
How many hospitalizations for diabetic ketoacidosis in 2009?
In 2009, there were 140,000 hospitalizations for diabetic ketoacidosis (DKA) with an average length of stay of 3.4 days.1The direct and indirect annual cost of DKA hospitalizations is 2.4 billion US dollars.
Why is bicarbonate not indicated in mild and moderate forms of DKA?
Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy.3, 8The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies.
How much volume loss in DKA?
Fluid loss averages approximately 6–9 L in DKA. The goal is to replace the total volume loss within 24–36 hours with 50% of resuscitation fluid being administered during the first 8–12 hours. A crystalloid fluid is the initial fluid of choice.10Current recommendations are to initiate restoration of volume loss with boluses of isotonic saline (0.9% NaCl) intravenously based on the patient’s hemodynamic status.3Thereafter, intravenous infusion of 0.45% NaCl solution based on corrected serum sodium concentration will provide further reduction in plasma osmolality and help water to move into the intracellular compartment. Hyperosmolar hyponatremia due to hyperglycemia is a frequent laboratory finding in DKA and is usually associated with dehydration and elevated corrected sodium concentrations.
What is the protocol for the management of patients with DKA?
The protocol for the management of patients with DKA is presented in Figure 1. It must be emphasized that successful treatment requires frequent monitoring of clinical and metabolic parameters that support resolution of DKA (Table 1).
When to start potassium supplementation after insulin treatment?
Start potassium supplementation after insulin treatment once [K +] is below the upper limit of the reference range.
When should venous glucose be measured?
Venous glucose should be measured hourly. Management should be based on capillary glucose measurements only after these have been found to agree with venous levels (at presentation the degree of hyperglycaemia may render the capillary measurement inaccurate).
What is the pH of DKA?
Defining DKA as serum glucose >250 mg/dl (>14 mM), metabolic acidosis with corrected pH<7.30 or serum bicarbonate <15 mM and ketonaemia, the sensitivity of urine ketone dip test for ketonaemia in patients with DKA is 97% (95% CI 92% to 99%). 5 The absence of ketonuria makes the diagnosis of DKA unlikely. It is possible that clinical staff in the study were using negative urine dip stick test to rule out DKA; the study would therefore overestimate its sensitivity. Few laboratories offer an urgent ketone level; an estimate of the severity of ketonaemia can be made from the anion gap (available immediately on some “blood gas analysers”); an anion gap >20 mM is abnormal.
What are the main features of DKA?
The main features of DKA are hyperglycaemia, metabolic acidosis with a high anion gap and heavy ketonuria (box 1). This contrasts with the other hyperglycaemic diabetic emergency of hyperosmolar non-ketotic hyperglycaemia where there is no acidosis, absent or minimal ketonuria but often very high glucose levels (>33 mM) and very high serum sodium levels (>150 mM). 3
Why is continuous insulin infusion used?
Continuous subcutaneous insulin infusions are commonly used in continental Europe to treat type I diabetes mellitus and their use is increasing in the UK. They were initially associated with an increased risk of DKA because of equipment failure. 18,19 As the technology has improved this risk has fallen. Treatment of DKA in patients usually treated with continuous subcutaneous insulin infusions does not differ from the conventional approach.
Why do we use soluble insulin?
A soluble insulin is normally used with the aim of permitting more rapid titration of circulating insulin levels (though there are no trial data comparing soluble against other types of insulin). If an intravenous bolus is followed by an intravenous infusion steady state insulin levels are reached very quickly. The half life of circulating insulin is five minutes; use of an intravenous infusion has the advantage over intermittent boluses of permitting a more rapid reduction in insulin level.
How often should blood potassium be measured?
Blood potassium levels should be measured hourly (hyperkalaemic and hypokalaemic cardiac arrest are common causes of death in patients with DKA 2)
How much insulin should I infuse?
The 2009 ADA consensus statement recommends either beginning with an insulin bolus of 0.1 units/kg or beginning an infusion of insulin at a rate of 0.14 units/kg/hr, without a bolus in adults. Boluses are not recommended in pediatric patients ( Kitabchi et al., 2009 ). If a bolus is used for an adult patient, it should be followed by a continuous infusion of insulin at a rate of 0.1 units/kg/hr. If the patient's blood glucose concentration does not decline by at least 10% of the original value in the first hour, a bolus of 0.14 units/kg may be given ( Kitabchi et al., 2009 ). In pediatric patients, continuous infusion of insulin should begin 1–2 hours after initial fluid resuscitation ( Wolfsdorf et al., 2007 ). For patients with excessive insulin sensitivity, it may be necessary to start the infusion of insulin at a lower or higher rate than recommended. In particular, the initial infusion rate for pediatric patients may need to be decreased to 0.05 units/kg/hr. Frequent injections of subcutaneous insulin may be used in place of continuous infusions, especially in mild DKA. However, continuous infusions are preferred because of faster onset, ability to titrate, and shorter half-life ( Kitabchi et al., 2009; Kitabchi, Umpierrez, Fisher, Murphy, & Stentz, 2008 ). Blood glucose concentrations should decline by 50–75 mg/dl/hr in adults. If this does not occur, the infusion rate of insulin may be increased hourly to achieve a steady decline of blood glucose concentration. Once blood glucose concentrations fall below 200 mg/dl, it may also be appropriate to decrease the infusion of insulin to 0.02–0.05 units/kg/hr to prevent hypoglycemia.
What are the causes of DKA?
Regardless of the inciting factor, the pathophysiology of DKA consists of insulin deficiency , which leads to decreased cell utilization of glucose. Insulin deficiency may be a consequence of insulin insufficiency and/or insulin resistance. Another important component is increased production of counterregulatory hormones such as glucagon, catecholamines, cortisol, and growth hormone. This, in conjunction with insulin deficiency, results in ketosis and accelerated glycogenolysis and gluconeogenesis, leading to hyperglycemia ( Koul, 2009 ). Hyperglycemia causes an increase in serum osmolality, which, in combination with decreased insulin, results in osmotic diuresis. This diuresis leads to many of the electrolyte abnormalities observed in DKA, namely, sodium, potassium, calcium, magnesium, chloride, and phosphate abnormalities. Osmotic diuresis can cause hypovolemia, which can be profound and may lead to decreased perfusion of organs including the kidneys ( Defronzo, Cooke, Andres, Faloona, & Davis, 1975; Kitabchi et al., 2001 ). Finally, decreased insulin action along with hormone alterations leads to lipolysis and free fatty acids are released. In the liver, free fatty acids are metabolized to ketone bodies. The accumulation of ketone bodies results in an anion gap metabolic acidosis characteristic of DKA.
How much NaCl should I take for resuscitation?
Initial fluid repletion in adults includes 0.9% NaCl administered at 15–20 ml/kg/hr over the first hour, or a total of 1–1.5 L in the first hour, in the absence of cardiac dysfunction. Further choice of intravenous fluids should be based on serum sodium concentration; patients with a normal or elevated corrected serum sodium concentration may receive 0.45% NaCl, whereas patients with a lower than normal serum sodium concentration should continue to receive 0.9% NaCl. Estimated fluid deficits should be repleted over the initial 24 hours ( Kitabchi et al., 2009 ). In either patient population, appropriate volume resuscitation may be monitored using blood pressure, heart rate, and urine output.
What is the most severe diabetic condition?
Diabetes, a chronic medical condition, continues to increase in prevalence. One of the most severe complications of diabetes, diabetic ketoacidosis (DKA), results from insulin deficiency and is a medical emergency that is frequently encountered in the emergency department. Prompt diagnosis, assessment of key laboratory values, appropriate treatment, and close monitoring are important to the successful treatment of this complex metabolic disorder. Fluid repletion and insulin administration are mainstays of DKA treatment and serve to restore normal hemodynamic status while decreasing the metabolic acidosis. Careful monitoring of glucose concentrations, vital signs, and electrolytes is essential to prevent complications arising from the treatment of DKA. This article provides an overview of the pathophysiology, presentation, diagnosis, treatment, monitoring, and complications of DKA.
What are the factors that contribute to DKA?
The inciting factors for developing DKA include infection, noncompliance, previously undiagnosed diabetes, pancreatitis, myocardial infarction, stroke, and medications . Although previously undiagnosed diabetes accounts for approximately 20% of presentations, infection remains the most common precipitating event for adults ( Kitabchi et al., 2001; Thewjitcharoen & Sunthornyothin, 2011 ). In contrast, pediatric patients have a high incidence of insulin noncompliance (unintentional or purposeful) leading to DKA ( McFarlane, 2011 ).
What are the complications of DKA?
Some of the most common complications arising from the treatment of DKA include hypoglycemia and hypokalemia. As previously discussed, both of these complications may be prevented by careful monitoring and addition of dextrose and potassium to maintenance fluids when appropriate. Another potential complication arising from excessive fluid resuscitation is chloremic acidosis, which can aggravate concurrent ketoacidosis. Recent evidence suggests that fluid resuscitation with a balanced electrolyte solution may lead to decreased incidence of chloremic acidosis in adults with DKA ( Mahler, Conrad, Wang, & Arnold, 2011 ). However, until additional evidence is available, initial fluid resuscitation per the 2009 ADA consensus statement should be strongly considered. If a chloremic acidosis develops, switching maintenance fluids to a formulation with a lower chloride concentration, such as a balanced electrolyte solution or lactated Ringer's, would be appropriate.
How many people were diagnosed with diabetes in 2010?
Diabetes continues to increase in prevalence, with the most recent data indicating that 1.9 million people were newly diagnosed in 2010 ( Centers for Disease Control and Prevention, 2010 ). Two of the most serious and life-threatening complications of diabetes are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state.
When is Type 2 diabetes diagnosed?
c. Type 2 diabetes is usually diagnosed when the client is admitted with a hyperglycemic coma.
Can exercise and diet control blood glucose levels?
d. Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes.
Can insulin be used to control blood glucose in type 2 diabetics?
a. Insulin is not used to control blood glucose in clients with type 2 diabetes.
Can insulin be used to control blood glucose?
Insulin is not used to control blood glucose in clients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Type 2 diabetes is usually diagnosed when the client is admitted with a hyperglycemic coma.
What is ECG in medical terms?
a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia.
What happens when insulin is insufficient?
a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood.
How many U/hr for insulin infusion?
a. Start an infusion of regular insulin at 50 U/hr.
What to do if your glucose is low?
If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. 27.
How long to infuse dextrose?
c. Administer a continuous infusion of 5% dextrose for 24 hours.
What is the name of the acid that is metabolized by the liver?
c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic.
How long after IV contrast should metformin be used?
Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately.
How many insulin injections are given to diabetics?
The client's diabetes is controlled with 2 injections a day, each consisting of isophane (NPH) insulin and regular insulin. One injection is given before breakfast and the other is administered before dinner.
What to do if you take a med while pregnant?
2. Notify the health care provider if you become pregnant as the medication is harmful to the fetus
What is a nurse teaching?
A nurse is teaching a class on the dietary management of diabetes mellitus to a group of clients diagnosed with type 2 diabetes mellitus. The nurse knows that the client most likely to benefit from using advanced carbohydrate counting (ACC) for meal planning is: 1.