Katie Arlinghaus KNH 413; Matuszak Case Study #2 February 18, 2014 Case 27: Type 1 Diabetes Mellitus with Diabetic Ketoacidosis 1. There are precipitating factors for diabetic ketoacidosis. List as least seven possible factors. Precipitating factors may include infection, insulin omission, inadequate insulin therapy, discontinuation of insulin use, myocardial infarction, cerebral edema, pancreatitis, stroke, trauma, and alcohol and drug abuse. (http://www.aafp.org/afp/2005/0501/p1705.html, http://www.ima.org.il/FilesUpload/IMAJ/0/38/19466.pdf) 2. Describe the metabolic events that led to the symptoms associated with DKA. Diabetes mellitus is the underlying cause of DKA. The pathogenesis of DKA involves insulin deficiency and an increased production of catabolic hormones such as glucagon, cortisol, catecholamines, and growth hormone. Insulin deficiency can come from lack of insulin production or inadequate intake of prescribed insulin. The lack of insulin causes hyperglycemia, which induces osmotic diuresis causing water and electrolyte loss. Ketosis can occur when ketones are used as an alternative energy source. Ketosis causes metabolic acidosis, which forces hydrogen ions into cells and displaces potassium ions lost through urine and vomiting. (https://www.clinicalkey.com/topics/endocrinology/diabetic-ketoacidosis.html) 3. Assess Susan’s physical examination. What is consistent with diabetic ketoacidosis? Give the physiological rationale for each that you identify. Susan’s dry membranes in her ears and nose and her intense thirst indicate dehydration. This is a common symptom of DKA because the build up of ketones cause more water to be drawn into the urine. Susan’s nausea and vomiting would only exasperate her dehydrated state. Furthermore, Susan’s breathing difficulty and tachycardia can be explained by DKA as well. The respiratory system has to compensate for her metabolic acidosis. Her pulse increased because her blood pressure decreased. Finally, the acetone smell of Susan’s breath is very telling of ketoacidosis as it is the smell of extra ketones, extra acid. (http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx) 4. Examine Susan’s biochemical indices both in the chemistry section and in her ABG report. Which are consistent with DKA? Why? Susan’s high K, PO4, osmolality, glucose, BUN, creatine, HbA1c, and low pH, CO2, and HCO3- levels are consistent with her DKA diagnosis. The buildup of ketones disrupts her electrolyte and acid-base balance. The extra acid is buffered by HCO3-, so its concentration in the blood increases. The academia causes an increase in breathing rate which decreases CO2. (http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx) 5. If Susan’s symptoms were left untreated, what would happen? If Susan’s symptoms were left untreated, the number of ketones in her blood would increase, disrupting the normal functioning of many parts of her body. It can cause dehydration, kidney failure, coma, respiratory distress syndrome, or even swelling of the brain. (http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx) 6. Assuming Susan’s SMBG records are correct, what events seem to have precipitated the development of DKA? If her SMBG records are correct, it seems that her volleyball tournament and her birthday precipitated her development of DKA. Although it isn’t completely understood, many women with diabetes demonstrate significant changes in glucose control associated with their menstrual cycle. (http://www.ncbi.nlm.nih.gov/pubmed/18414069) 7. What, if anything, could Susan have done to avoid DKA? One of the main things she could have done to avoid DKA would have been to keep her blood glucose levels consistent. This means taking her insulin, keeping her carbohydrate intake consistent, and drinking more water. Although she says that she was following her meal plan and prescription, her glucose levels were clearly not consistent. Perhaps her plan needs to be changed, especially during times of high activity such as her volleyball tournament. Her period may have also complicated matters. To prevent DKA, when she begins to see her blood glucose levels raise she should check her ketone level. (http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx) 8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does “IV piggyback” mean? What is Tagamet, and why has it been prescribed? An IV piggyback is a device that allows various fluids to be given at different rates. The mechanism that controls the rate of delivery is kept separate but the IV access line is shared. This allows her to be given medicine on top of the general IV saline solution. Tagamet is the brand name for cimetidine, which is used to decrease the amount of acid in the stomach. This would help lower her pH, which were low according to her lab values. (http://www.rxlist.com/tagamet-drug.htm) 9. The Diabetes Control and Complications Trial was a landmark multicenter trial designed to test the proposition that complications of diabetes mellitus are related to elevation of plasma glucose. It is the longest and largest prospective study showing that lowering blood glucose concentration slows or prevents development of complications common to individuals with diabetes. The trial compared “intensive” insulin therapy (“tight control”) with “conventional” insulin therapy. Define “intensive” insulin therapy. Define “conventional” insulin therapy. Intensive insulin therapy is an aggressive treatment approach designed to control your blood sugar levels by administering frequent doses of insulin. It involves non-scheduled meal times and up to 4 injections of insulin daily. Conventional insulin therapy is An older method that intensive insulin therapy. It involves having scheduled meals with 2-3 injections of insulin daily. (http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866) 10. List the microvascular and neurologic complications associated with type 1 diabetes. Microvascular complications include: diabetic etinopathy, aldose reductase, oxidative stress, growth factors, diabetic nephropathy, and proteinuria. Neurologic complications include peripheral neuropathy, diabetic neuropathy, chronic sensorimotor distal symmetric polyneuropathy, numbness, burning, tingling, electrical pain, and sensory loss. (http://clinical.diabetesjournals.org/content/26/2/77.full) 11. What are the advantages of intensive insulin therapy? Advantages to intensive insulin therapy include: preventing or slowing the progression of long-term diabetes complications; reducing the risk of eye damage, reducing the risk of nerve damage, slowing or preventing the progression of kidney disease, and help boost the patient’s energy. (http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866) 12. What are the risks of intensive insulin therapy (tight control)? Risks of intensive insulin therapy include weight gain and low blood sugar. (http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866) 13. Dr. Green consults with you, and the two of you decide that Susan would benefit from insulin pump therapy combined with CHO counting for intensive insulin therapy. This will give Susan better glycemic control and more flexibility. What are some of the key characteristics of candidates for intensive insulin therapy? Candidates for intensive insulin therapy should not be children or elderly, should not frequently struggle with severe bouts of low blood sugar, do not have heart or blood vessel disease, and should be active. Susan meets these criteria. (http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866) 14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump? Insulin pumps release insulin into the body through a plastic tube that is placed under the skin of the abdomen. The pump delivers continuous infusion of short-acting insulin and bolus before meals. The pump is the size of a charger and is operated with batteries. Of possible treatment options, the insulin pump most closely mimics natural insulin secretion. Base on the patient history provided, Susan would be a candidate for an insulin pump. (Page 489, http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensiveinsulin-therapy/ART-20043866) 15. How would you describe CHO counting to Susan and her family? I would explain that CHO counting is a meal planning approach that concentrates on the total amount of carbohydrate eaten at meals and in snacks. It is based on research that demonstrates how consistent intake of a wide variety of carbohydrates results in similar postprandial glucose responses. Awareness of carbohydrate intake and distribution has been shown to improve metabolic control. I would explain to them that she could look on labels for total carbohydrate grams or use carbohydrate choices where one choice=15 grams carbohydrate. (Page 492-493) 16. How is CHO counting used with intensive insulin therapy? CHO counting is used with intensive insulin therapy by calculating the insulin-tocarbohydrate ratio to determine proper insulin dosages based on carbohydrate intake. Generally 1 unit of rapid-acting insulin is taken for every 10-15 grams of carbohydrates. This can be used as a starting point and then adjusted according to Susan’s SMBG records. (Page 493) 17. Estimate Susan’s daily energy needs using the Harris-Benedict equation. 655 + (9.56 x wt) + (1.85 x ht) – (4.68 x age) 655 + (9.56 x 57.2kg) + (1.85 x 160.02cm) – (4.68 x 16years) 655+ (546.832) + (296.037) – (74.88) =1,422.989 kcal x 2.0 physical activity/stress factor = 2,845.978 kcal (Page 241) 18. Using the 1-week food diary from Susan (next page), calculate the average amount of CHO usually consumed each meal and snack. Breakfast: (112+112+97+112+112+102+102)/7days= average of 107 grams CHO Lunch: (115+115+100+102+115+120+120)/7days= average of 112 grams CHO Snack: (85+30+55+30+45+45+15)/7days= average of 43 grams CHO Dinner: (325+72+115+120+140+100+120)/7days= average of 142 grams CHO HS: (15+15+55+15+85+65+65)/7days= average of 45 grams CHO (Page A109-A123) 19. After you have calculated Susan’s usual CHO intake from her food record (question 18), develop a CHO-counting meal plan that she could use. Include menu ideas. Daily total: 391g CHO; 142g protein; 79g fat; 2,845 calories 2,845kcal*.55=1,564kcal/4kcal per gram CHO=391g CHO/15g per serving=26 CHO choices 2,845kcal*.2=569kcal/4kcal per gram protein=142g Protein/7g per serving=21 servings 2,845kcal*.25=711kcal/9kcal per gram fat=79g Fat/5g per serving=16 Time 7:00-8:00am CHO Choice or Grams CHO 6 CHO choices or 90 g CHO 4 oz meat/meat substitutes 3 servings fat 3 CHO choices or 60 g CHO 2 oz meat/meat substitutes 2 servings fat Menu Ideas 1 cup of Cheerios with ½ cup 2% milk, 1 banana with 1 T peanut butter 3 oz pretzels with peanut butter or hummus, or a yogurt with fruit and nuts 1:00-2:00pm 6 CHO choices or 90g CHO 5 oz meat/meat substitutes 3 servings fat 4:00-5:00pm 3 CHO choices or 60 g CHO 2 oz meat/meat substitutes 2 servings fat 6 CHO choices or 90 g CHO 6 oz meat/meat substitutes 3 servings fat Turkey sandwich: 2 slices whole wheat bread, 2 oz deli turkey, lettuce, tomato, 2 tsp mayonnaise, mustard 1 medium apple, 1 oz carrot sticks 2 T fat-free Ranch dressing Graham crackers or apples with peanut butter or 2 apples 10:00-10:30am 6:30-7:30pm 9:00-10:00pm 2 CHO choices or 60 g CHO 2 oz meat/meat substitutes 3 servings fat 3 oz chicken breast- grilled with bbq sauce, side salad with fat-free dressing, 1 small baked potato with sour cream and cheese, 1 8-oz glass of 2% milk, 1 small slice of cake ½ Cup Ice Cream with chopped nuts, fruit topping, in a waffle bowl 20. Just before Susan is discharged, her mother asks you, “ My friend who owns a health food store told me that Susan should use stevia instead of artificial sweeteners or sugar. What do you think?” What will you tell Susan and her mother? I would tell Susan and her mother that Stevia is a non-caloric sweetener that is 20-30 times sweeter than sugar, however it still has carbohydrates. Some people do not like the after taste of Stevia. There are questions about the toxicity of Stevia. Until 2008, the FDA allowed it to only be sold as a dietary supplement. It has been given GRAS (generally recognized as safe) status. (http://www.eatingwell.com/nutrition_health/nutrition_news_information/is_stevia_safe) Works Cited Barski, Leonid. "diabetic Ketoacidosis: clinical characteristics Precipitating Factors and outcomes of care." Israel Medical Association Journal. N.p., n.d. Web. 15 Feb. 2014. <http://www.ima.org.il/FilesUpload/IMAJ/0/38/19466.pdf>. "Clinical Diabetes." 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Web. 15 Feb. 2014. <http://www.eatingwell.com/nutrition_health/nutrition_news_information/is_stevia_safe >. Nelms M, Sucher K, Lacey, K., Habash, D., Roth S. Nutrition Therapy and Pathophysiology. 2nd ed. Belmonte, CA: Thomson Brooks/Cole, 2010. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 15 Feb. 2014. <http://www.ncbi.nlm.nih.gov/pubmed/18414069>. "Tagamet (Cimetidine) Drug Information: Description, User Reviews, Drug Side Effects, Interactions - Prescribing Information at RxList." RxList. N.p., n.d. Web. 15 Feb. 2014. <http://www.rxlist.com/tagamet-drug.htm>.