Introduction

Diabetic ketoacidosis is considered one of the most life-threatening complications of diabetes mellitus. More importantly, it is also one of the most preventable complications of diabetes. Through proper education and empowerment of persons with diabetes to self-manage this chronic medical condition, the overall mortality rates associated with this complication have steadily declined in the United States. An interdisciplinary team approach (including medical providers, social workers, case managers, and community resources) has been proven to reduce recurrences of DKA in vulnerable populations. (2)

Definition

DKA, or diabetic ketoacidosis, is defined as a potentially life-threatening medical condition that occurs in people with diabetes. While it usually occurs in persons with type 1 diabetes mellitus, who are dependent on daily insulin injections, it may also occur in individuals with type 2 diabetes for a variety of reasons (underlying physiologic stress, such as an acute infection or trauma, or uncontrolled blood glucose levels and missed routine diabetic medications).

In an acute case of diabetic ketoacidosis, the body is not producing enough insulin to move glucose into the cells for energy, and the liver then begins to break down fat for fuel instead, producing ketones. This buildup of ketones in the body results in ketoacidosis. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and eventual death. (3)

Epidemiology

Epidemiology is the study of how often a disease process occurs in different populations. By studying the rates of occurrence, epidemiologists can evaluate treatment options and develop long-term strategies to lower the risk of ongoing or recurrent disease-related episodes.

Diabetic ketoacidosis is currently a leading cause of both morbidity and mortality in children with Type 1 diabetes. It usually occurs at the time of the initial diagnosis in as much as 30-40 percent of the children in the United States alone. In children living with a confirmed Type 1 diabetes condition (previously diagnosed), these percentages decrease to average rates of 6-8 percent annually.

The drastic reduction of such occurrences is believed to be directly related to ongoing patient and family education and medication adherence. Diabetic ketoacidosis is potentially life-threatening, but it is, for the most part, also preventable. Throughout this educational offering, key components of patient education in diabetic self-management, including reducing the risk of diabetic ketoacidosis, will be discussed (4) (5).

By comparison, other countries, challenged by annual income, healthcare access, cost management, and food insecurity, do not fare so well. Various studies were funded by the Leona M. and Harry B. Helmsley Charitable Trust and the Juvenile Diabetes Research Foundation Ltd. Several countries included in these studies were deemed “LLMIC” (low and low-middle-income countries). Countries, including Haiti, Ethiopia, Senegal, Nepal, and Tanzania, to name a few, were found to have inadequate supplies, medications, and equipment to both initially diagnose and successfully manage diabetes mellitus long term. Critical items necessary for the treatment and stabilization of acute diabetic ketoacidosis were in even shorter supply. These barriers to treatment resulted in delayed or missed diagnoses, increased overall complication rates, and premature deaths.

“Evidence from single-center studies suggests that DKA in new-onset T1D is more common in LLMICs compared to upper and upper-middle income countries, with rates ranging from 62.2 to 77.1% in Nigeria, 69.8% in South Africa, and 92.1% in Sudan. In comparison, in upper and upper-middle income countries in North America and Europe the rates range from 14.7% (Denmark) to 42.0% (France”). (6)

Ongoing education of healthcare professionals and patients/families alike, coupled with the availability of and easy access to self-management medications and monitoring equipment, positively affects DKA-related health outcomes and the quality of health and well-being.

The development of insulin delivery systems (insulin pumps) has further positively impacted the rate of DKA occurrence. Patient comfort, ongoing education, streamlined medication delivery, and enhanced monitoring systems have afforded patients with diabetes a better understanding of their condition and empowered them to successfully self-manage their health conditions. While reported rates of DKA in previously diagnosed persons with T1DM were 6.3% in one study, that number decreased to 2.2% at 3 years out.

Ongoing improvements in closed insulin delivery systems medication continue to improve (lower) DKA occurrence rates compared to those previously using multiple daily injection therapy. The development of continuous glucose monitoring (CGM) devices, in addition to insulin delivery systems, provides for early detection and treatment of both hypoglycemia and hyperglycemia. The addition of remote app devices further allows constant monitoring and two-way communication between patients, family members, and even healthcare providers.

Sadly, the population identified as being at highest risk for DKA is that of children who are uninsured/underinsured, lacking the insurance coverage for many closed delivery medication systems, as well as specialty care (pediatric endocrinology) provider access.

The acute complications associated with DKA account for a high percentage of premature deaths in T1DM patients under the age of 30 years. (7) Given these statistics of prevalence and incidence rates, DKA is an ever-increasing global concern that is best addressed and managed through ongoing, patient-specific disease management education.

The prognosis for DKA worsens in the presence of coma, hypotension, and in the presence of severe (chronic and acute) comorbidities. Yet, with early identification, ongoing education, and improved glucose monitoring/treatment options, DKA, which is often life-threatening, is also highly preventable. The goal, therefore, is to ensure all patients with diabetes mellitus are given equal opportunity to access both the education and materials necessary to monitor their health condition successfully. (8)

Pathophysiology

Diabetic ketoacidosis occurs when the body is under stress and responds with an increase in catecholamines, cortisol, and growth hormones. The release of such hormones decreases the ability of insulin, further increasing insulin resistance and resulting in serum hyperglycemia. Without cellular glucose for energy,y the body then begins to break down fat and protein for energy, resulting in increased levels of serum ketones. The combination of hyperglycemia and ketosis, as well as dehydration and various electrolyte imbalances, forms the basis of diabetic ketoacidosis. (9)

While it is believed that the omission of insulin (nonadherence/ noncompliance, or mechanical failure of insulin delivery systems) accounts for the largest percentage of DKA admissions, other factors may be responsible for the development of this condition. Any disease process that increases insulin resistance, impairs insulin secretion, or interferes with carbohydrate metabolism may contribute to the onset of acute diabetic ketoacidosis in a vulnerable, health-compromised patient.

Clinical Signs and Symptoms

The underlying presence of hyperglycemia, ketoacidosis, and ketonuria causes diabetic ketoacidosis. Early signs and symptoms may include any of the following:

• Generalized weakness and fatigue.
• Nausea and vomiting
• Diffuse abdominal pain.
• Decreased appetite and anorexia.
• Decreased/ altered levels of consciousness, such as mild disorientation and confusion.
• Dry skin, mucus membranes, and decreased perspiration
• Tachycardia (increased heart rate) and tachypnea (increased respiratory rate)
• Acetone/ketone smell on breath
• Significant weight loss (usually a rapid onset in the newly diagnosed Type 1 diabetes mellitus patients)
• A patient history of noncompliance with prescribed insulin therapy (due to coexisting medical issues in which the patient may have intentionally stopped insulin due to decreased food/fluid intake), cost factors (unable to afford prescribed therapy), and missed insulin doses (mechanical failure of the patient’s current insulin delivery system).

Additional signs and symptoms may be present, related to the patient’s age. While an adult patient would be able to verbalize symptoms, a child may not be able to do so, especially in cases where the diagnosis of T1DM is made during the child’s initial presentation to an emergency department for suspected DKA.

Other factors (illness, injury, medication side effects) may cause DKA to occur in all cases; thus, thorough examination and diagnostic testing must be done in all cases prior to the initiation of treatment. Likewise, discharge planning and ongoing follow-up care must be patient-specific to address behaviors and treatments required for optimal health maintenance.

Teens/Young Adults

In the teenager/ young adult population, the following symptoms may occur: (11)

• Increases in urination, thirst, and appetite.
• Unintentional/ unexplained weight loss despite increases in food and fluid intake.
• Changes in energy level (increased fatigue)
• Vision changes

Please note that normal growth and development stages/patterns in teenagers and young adults will influence glucose metabolism (which is related to hormone levels).

Young Children

In the young children’s population, symptoms usually strike suddenly and, unlike the adult population, are usually not related to a specific lifestyle or dietary practice. Most children present with the following symptoms:

• Increased urination
• Increased thirst
• Fatigue
• Vision problems (blurred vision)
• Acetone/ketone “fruity smell” on breath
• Unexplained weight loss, often despite appearing to eat (and drink) more.
• Changes in mood and behavior

Infants/Toddlers

In the infant/toddler population, symptoms may present as follows:

• Increased food and fluid intake (always appearing thirsty despite normal fluid intake)
• Frequent urination (in the potty-trained child, this may present as a new onset of bed wetting behaviors)
• Increasing fatigue and changes in normal activity levels
• Unexplained weight loss despite increased food and fluid intake
• Increased occurrences in diaper rashes (suspected increase in yeast infection)
• Fruity/acetone smell to breath
• Unusual behavior (child-specific)

Etiology

Etiology: Causes of Diabetic Ketoacidosis

Hyperglycemia and low insulin levels lead to diabetic ketoacidosis. Common causes include the following:

• Acute illness alters a person’s food or drink intake, making glucose management more difficult. This is a twofold situation. The person with diabetes, recognizing the change in their normal food/fluid intake, may also choose to intentionally decrease/skip their routine diabetic medications to avoid episodes of hypoglycemia.
• Insufficient levels of insulin due to the demands of normal growth and development patterns in children and young adults.
• Missed insulin doses (intentional decision to take inadequate doses, inadvertently held doses, inaccurate dose amounts, clogged insulin pump tubing).

Other causes of DKA, unrelated to insulin dose administration, are thought to be related to increased stress levels (inflammation/ infection) and normal hormone disruption, physiologic stressors. People with Type 2 diabetes may experience DKA due to prolonged, untreated hyperglycemia. (12), (13)

• Myocardial infarction
• Neurological stroke
• Motor vehicle accident with physical injuries (inflammatory response to blunt force/penetrating trauma)
• Abuse of alcohol and illegal drugs
• Medication side effects (diuretic and corticosteroid *use) see below
• Severe or prolonged illness (such as pneumonia and urinary tract infection/ urosepsis/wound infections)

Etiology: Precipitating Factors

Common precipitating factors for diabetic ketoacidosis include the following (14):

• Poor compliance with prescribed insulin therapy (intentional, nonintentional)
• Infections (especially T2DM in the elderly/ adult population)
• Newly diagnosed diabetes (especially T1DM in the pediatric/juvenile population)
• Physiological-based stressors, including coronary syndrome, cerebral vascular accidents, ischemic injuries, shock-like states, chronic alcoholism, illicit drug use, and certain antipsychotic medications.

Etiology: Diabetic Ketoacidosis and Corticosteroid Use

Diabetic ketoacidosis is related to long-term corticosteroid usage. Hyperglycemia has been reported in a large percentage of patients who are using corticosteroids long term, often as high as “64-71%”. The elevated glucose levels combined with the ongoing physiologic stressors warrant the use of these medications, which increase the risk of DKA. The benefit/risk of using these medications long term must be assessed, especially in patients with pre-existing metabolic risk factors. Ongoing patient monitoring is essential to lower the risk of long-term complications. (15) (16).

Risk factors that “may” increase the likelihood of developing type 2 diabetes after long-term steroid usage include the following:

• Overweight (BMI 25.0 -29.9 percent) / obesity (BMI 30 percent or above)
• History of gestational diabetes
• History of polycystic ovarian syndrome
• History of family members with type 2 diabetes

Treatment

Emergency Treatment

The initial or emergency treatment of diabetic ketoacidosis may require complex, frequent monitoring, often necessitating an intensive care admission. The following generic guidelines refer to intensive care nursing management. Please refer to your specific organization for nursing protocols related to DKA management. Many facilities have strict admission guidelines to ensure the appropriate use of intensive care resources. With respect to patients with DKA, suitable ICU admissions may include the following:

• A newly diagnosed diabetic during an episode of DKA
• Any infectious disease condition that triggers an episode of DKA
• An episode of DKA occurring concurrently with a physiologic stressor event (acute myocardial infarction, cerebrovascular accident/stroke)

The goals of emergency treatment of diabetic ketoacidosis are multifactorial and listed below. Interventions will include, but not be limited to, insulin intravenous infusions, hourly vital sign monitoring (or more frequent), and hourly glucose checks.

• Treatment/correction of dehydration with IV fluids
• Treatment of hyperglycemia with insulin therapy
• Treatment of electrolyte imbalances
• Treatment/correction of acid-base imbalance

Initial/Emergency treatment of DKA includes (20):

• Initial assessment and stabilization of ABC airway, breathing, and circulation.
• Aggressive fluid therapy to restore circulating volume.
• Isotonic saline IV infusion
• IV with dextrose component once glucose level 200-250mg/dl

Laboratory Findings

The following laboratory ranges provide a generic overview of normal ranges and abnormal findings associated with DKA (17) (18) (19). Laboratory findings and patient assessment are required to confirm acute diabetic ketoacidosis. Please refer to your specific medical organization (unit-specific) for further guidance and treatment parameters.

• Serum potassium levels: Normal range (3.5 to 5.0 mEq/L); hyperkalemia ranges approximately 5.0 to 5.5 mEq/L. 
• Serum sodium levels: Normal range (137 to 142 mEq/L) severe hyponatremia range approximately 125mEq/L or lower; severe hypernatremia range above 145mE/L 
• Serum Amylase level: Normal range (40 to 140 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Lipase level: Normal range (0-160 units per liter) (U/L); may be elevated in cases of pancreatitis/ pancreatic inflammation, which may coexist with DKA 
• Serum Osmolality level: Normal range 275-295 mOsm/kg: may be elevated to between 300-320 mOsm/kg in DKA       
• Arterial blood gas analysis: Arterial pH below 7.3 (normal range 7.35-7.45)   
• Anion Gap: Normal 4-12 mEq/L ; levels above  > 10 may indicate existing acidosis in DKA 
• Serum glucose level (normal fasting below 100mg/dl). Hyperglycemia ranges above 250mg/dl 
• Serum ketone level (normal negative); serum ketones detected in blood; usually greater than 5mEq/L       
• Serum bicarbonate level (normal 22-29 mEq/l); usually less than 18mEq/L  
• Anion gap level (normal 4-12mmol/L); usually greater than 12 mmol/L)

To rule out physiologic stressors associated with the development of DKA (systemic infections, acute myocardial infarction, pneumonia, urosepsis), refer to your medical organization (unit-specific) guidelines regarding these additional diagnostics:

• Serial blood and wound cultures
• Serial EKG and Troponin levels
• Sputum cultures and sensitivity
• Urinalysis and culture with sensitivity
• Chest Xray

Fluid Resuscitation Guidelines

The American Diabetes Association (ADA) recommends the following initial fluid resuscitation in the adult population; additional boluses may be required after each hourly reassessment (21). Please refer to your unit’s specific guidelines regarding fluid boluses and fluid resuscitation. Caution is advised when using fluid boluses with patients with preexisting heart failure, kidney failure, or other medically indicated “fluid restrictions.”

0.9% SC (Sodium Chloride Solution) initially as a 15–20 mL/Kg bolus for hemodynamic resuscitation

• Then 250–500 mL/h of fluid until glucose is normalized (usually faster than DKA resolution) 
• Then 150–250 mL/h until DKA resolution  
• For the replenishment, 0.45% SC (Sodium Chloride Solution) unless hyperglycemia-corrected hyponatremia is present.

In the pediatric population, fluid resuscitation boluses are indicated in children who present with the following symptoms: (22)

• Dry mucus membranes 
• Poor skin turgor 
• Lethargy, altered level of consciousness. 
• Nausea and vomiting 
• Tachycardia and tachypnea 
• Kussmaul-type respirations (deep and labored breathing patterns)

Fluid recommendation: 10–20 mL/kg bolus of isotonic saline given over 30–60 mins.

Insulin Therapy and Acute Diabetic Ketoacidosis

Intravenous use of insulin is preferred in patients with acute diabetic ketoacidosis, as subcutaneous absorption of insulin would most likely be ineffective in light of dehydration.

Intravenous continuous infusion of insulin at a rate of 0.14 U/kg/hour or

Insulin bolus of 0.1U/kg, followed by insulin continuous infusion at a rate of 0.1U/kg/hour.

Hourly (or more frequent glucose checks) with a decrease in insulin delivery dose when glucose level is 250mg/dl or less. At this time, the insulin dose is further decreased to 0.05 or 0.1U/kg hourly until DKA is resolved. 

• Patients, once stabilized and deemed able to eat, can be transitioned to subcutaneous insulin administration and routine glucose monitoring (point of care/ POC glucometers)

Laboratory Tests Guidelines Therapy Goals

• Serum glucose levels below 200mg/dl 
• Serum bicarbonate level greater than 15mEq/L 
• Serum potassium level 4.0 -5.0 mEq/L 
• Venous pH greater than 7.30  
• Anion gap equal to/less than 12eEq/l. (23)

Electrolyte Imbalance (Hyperkalemia-> Hypokalemia)

Serum potassium levels are usually high/elevated due to the cellular changes occurring as a result of acidosis and decreased insulin. Electrolyte replacement should be monitored very closely in diabetic ketoacidosis. During the rehydration/ volume restoration phase and insulin administration, extracellular potassium shifts back into the intracellular space (causing hypokalemia). In addition, insufficient insulin levels may deplete various serum electrolytes; thus, frequent serum electrolyte levels with appropriate intravenous replacement ensure proper cellular activity.

Treatment-Related Complications

• Hypoglycemia (blood glucose levels below 70mg/dl): Treat. Accordingly, the patient should be transitioned to subcutaneous insulin injections when the serum glucose level is 200-250mg/dl and the patient is able to tolerate oral intake.
• Hypokalemia (blood potassium levels below 3-3.4 mmol/L): intravenous therapy to include potassium supplements; oral supplements as tolerated once the patient transitions to a diabetic diet.
• Cerebral edema

Cerebral Edema

Cerebral edema, or brain swelling, occurs in a variety of conditions (brain tumors, blunt trauma, inflammatory conditions, and even infections). Diabetic ketoacidosis and hyponatremia can cause cerebral edema. (24) Cerebral edema is the leading cause of mortality in children. A normal ICP (intracranial pressure) reading is 7- 15 mmHg; an increased reading in excess of 20- 25 mmHg, coupled with the following symptoms, may be indicative of cerebral edema.

Initial symptoms of cerebral edema may include the following:

• Headache 
• Visual changes (double vision (diplopia) or blurred vision) 
• Changes in speech/ ability to talk/ personality. 
• Nausea and vomiting 
• Changes in level of consciousness (lethargy-> unresponsiveness) 
• Changes in respirations/ difficulty breathing

Symptoms that may indicate worsening of cerebral edema. 

• Decorticate and decerebrate posturing. 
• Cranial nerve palsies  
• Fluctuating level of consciousness 
• Sustained heart rate deceleration, 
• Increased vomiting, headache, and lethargy 

Confirmation Testing: 

• CT (Computerized Tomography) scan 
• MRI Magnetic Resonance Imaging

Treatment for DKA-Related Cerebral Edema

When cerebral edema is confirmed by radiologic testing, the administration of Mannitol (or hypertonic sodium) is recommended as follows (25) (26):

• 0.5-1 g/kg intravenous mannitol may be given over the course of 20 minutes and repeated if no response is seen in 30-120 minutes.  
• If no response to mannitol occurs, hypertonic saline (3%) may be given at 5-10 mg/kg over 30 minutes. 
• Additional treatments may be warranted, including diuretics, corticosteroids, and possible surgical intervention (to prevent herniation syndrome).

Nursing Care and Management

Nursing Care: Patient Placement

Initial/hourly (or more frequent) assessment to include the following:

Due to the frequency of monitoring and medication administration during the acute phase of DKA, patients are usually placed in the Intensive Care Unit (ICU). ICU treatment often includes hourly physical assessments (intake, output, neurological assessment, vital signs); frequent laboratory testing (glucose testing); and rapid identification of complications (cerebral edema, hypoglycemia, hypokalemia).

Transfer to a step-down unit usually occurs when the patient is fully awake, tolerates oral intake (solid food and liquids), has stable vital signs, and has complete fluid and electrolyte replacements. The average timeline may be 1-2 clinical days. The focus of care now shifts to discharge planning, patient education, and ongoing management.

Nursing Care: Acute Phase

• Monitoring of vital signs, level of consciousness/ neurological status, and urine output
• Administration of IV fluids as ordered.
• Frequent blood glucose assessment and insulin administration

Nursing Care: Patient Education, Discharge Planning, and Follow-up Care

• Compliance with medications, a healthy diet, glucose monitoring, and sick day management
• Signs and symptoms of infection
• Importance of follow-up care with primary medical provider/endocrinologist
• Lifestyle behavior changes (smoking cessation, physical activity, healthy diet)
• Medical Alert ID bracelet or wallet insert regarding chronic medical conditions and medication.
• Coordination of follow-up care to ensure ongoing medical support, educational services, and financial assistance when appropriate (medical provider, endocrinologist, pharmacist, social worker/ case management services, DSMES classes) (27)

Patient Education

Diabetes Self-Management Education and Support (DSMES)

The Centers for Disease Control and Prevention offer a Diabetes Self-Management Education and Support Toolkit on their website, available to the public. It is designed for various health organizations/ community organizations, and others interested in educating people with diabetes to live a healthier lifestyle. Studies have shown that people who receive such education have better overall health and well-being. Despite these studies, a very low percentage of those qualified to receive such services access them. Check out the link below for more information.

• DSMES Program Review: https://www.cdc.gov/diabetes/dsmes/index.html
• DSMES Toolkit: https://www.cdc.gov/diabetes/dsmes-toolkit/index.html

Additional Resources

The following websites are being provided to assist the healthcare professional in accessing appropriate diabetes-related information, including information on insulin coverage, food insecurities, food bank locations, and DSMES. https://diabetes.org/

The American Diabetes Association provides information on prediabetes, Type 1, and Type 2 diabetes, as well as gestational diabetes. Their website includes sections on medications, support groups, diet and activity, advocacy efforts, and prevention efforts. https://www.jdrf.org/

The Juvenile Diabetes Research Foundation is a global organization for Type 1 diabetes mellitus. The site offers information on all things T1DM, including sections for those newly diagnosed, those interested in fundraising, research, and clinical trials, daily diabetes management, volunteer opportunities, and access to local chapters worldwide. From the healthcare provider’s perspective, this website offers continuing education programs and PDF downloads for patient-specific education. https://getinsulin.org/

The Get Insulin website provides information for persons with diabetes to access affordable insulin coverage. The site also offers information and guidance on health insurance plans, an insulin-related newsletter, and external links to food sources (for patients with food insecurity issues) https://www.feedingamerica.org/find-your-local-foodbank

The Feeding America website enables persons with food insecurities to access food banks in their area, according to their state location and zip code.

Safety Considerations

Successful management (prevention) of diabetic ketoacidosis requires patient education and empowerment in managing situations where glucose levels may be elevated and/or insulin levels (doses) are substandard (29).

There are many situations that can put a patient at risk for the development of DKA, including the following (29):

• Illness (acute and chronic) affects normal food and fluid intake and negatively affects glucose management.
• Missed medication (insulin therapy) due to a clogged insulin pump tubing, a malfunctioning insulin pump, partial doses/skipped doses of insulin (whether related to costs, cognition, or mental health issues {diabetes distress}),
• Medication side effects
• Concurrent use of alcohol or drugs
• Physiological stress (heart attack, stroke, physical injury)

Patient Education: Sick Day Management

Home treatment/ self-care (30)

The importance of preplanning cannot be understated. All persons with diabetes should have adequate supplies at home to address an acute illness, including medications to treat basic symptoms before they escalate. These medications may include over-the-counter medications to treat pain, nausea, vomiting, diarrhea, as well as adequate supplies to manage their diabetes (alcohol prep pads, syringes, prescription medications).

In addition, it is important to stock up on diabetic-friendly foods and drinks to maintain nutrition and hydration levels during an acute illness. Such items might include sports drinks, soft drinks, instant-cooked cereals, puddings, and soups. In the event that a patient cannot eat their regular meals, the goal is to eat or drink 50 grams of carbohydrates every 4 hours to maintain glucose levels.

Sick Day Management Guidelines

• Monitor glucose levels every 4 hours.
• Stay hydrated – 4 to 6 ounces of fluid every ½ hour to prevent dehydration.
• Daily weight
• Temperature checks (rule out underlying infection)
• Current medication compliance- do not stop taking insulin or diabetic oral agents. ** Notify the provider immediately if you choose to stop medications.

Seek emergency care for the following signs/ symptoms:

• Persistent vomiting/diarrhea to the point that you cannot tolerate any food or fluid intake for several hours
• Ongoing glucose levels above 240mg/dl
• The presence of moderate/high levels of ketones in urine
• Unexplained weight loss during an illness
• Any difficulty breathing
• Fruity/acetone smell on breath
• Changes in gait/balance/ vision

Research Findings

Research: Diabetes Distress and Burnout

Diabetes is a 24/7/365 chronic medical condition. Unlike many conditions that are simply managed with lifestyle changes or a single, once-a-day medication regimen, diabetes mellitus requires lifelong, around-the-clock commitment. Whether diet, activity, or medication management, a person with diabetes may easily feel overwhelmed by even the basic requirements for self-management. (31)

Ongoing health challenges, comorbid medical conditions, medication and diet cost issues, and family dynamics can all affect a person’s ability to manage any health condition successfully. When emotions (sadness, anger, hostility, frustration, and even fear) become overwhelming, diabetic distress (a feeling of defeat) can often occur. Without prompt, patient-specific interventions (mental health services, financial assistance, self-management education), these feelings will progress to diabetic burnout and increase the risk of unhealthy habits (poor medication adherence and overall glycemic control). (32)

Diabetes distress can easily progress to diabetes burnout without appropriate ongoing medical treatment and mental health interventions. When a person with diabetes reaches the point of burnout, they often appear to disconnect from their routine healthcare, exhibiting indifference towards their overall health and well-being. They may become both mentally and physically exhausted from the daily requirements of this chronic medical condition. At this point, it is not uncommon to observe a person’s total disregard for their ongoing medical treatments, daily medications, routine self-care, and more. Missed medications, missed medical appointments, poor dietary intake, and a visible lack of basic hygienic practices are cause for concern.

A multidisciplinary approach to treating suspected diabetic distress and burnout is highly encouraged. From ongoing education, physical and mental health assessments, and enrollment in therapies (individual therapy sessions and support groups), the person with diabetes needs a supportive environment in which to become empowered in the self-management of their disease progression. In doing so, health outcomes are believed to be optimal, and the risk of long-term complications is lowered. (33)

Research: Diabulimia

Bulimia nervosa is a potentially life-threatening eating disorder characterized by episodic binge eating of large amounts of food, followed by forced vomiting and possibly laxative use to “purge” the food. These alternating behaviors are the result of a person’s fear of weight gain and willingness to lose weight in unhealthy ways. (34) (35)

Diabulimia is a serious, life-threatening eating disorder affecting persons with Type 1 diabetes. Through intentional restricted/ limited use of prescribed insulin, weight loss occurs. This eating disorder is more common in young female adolescents and young adults. (34) (35)

Signs and symptoms may include the following (34) (35):

• Unexplained weight loss
• Hemoglobin A1C > 9
• Multiple episodes of DKA
• Unfilled insulin prescriptions, missed diabetes-related medical appointments,
• Expressed fear of insulin-related weight gain
• Anxiety related to body image
• Obsessive interest in calories and dieting

Research: Insulin Affordability

For many persons with diabetes, the perceived noncompliance with therapy (on behalf of the healthcare professional) is actually that of a cost-related issue. Many people cannot afford ongoing therapies related to the management of this chronic medical condition. In attempts to “cut costs”, patients have admitted to skipping certain medications, cutting medications in half, reducing prescribed doses of insulin, and purchasing poorer quality, less expensive foods (that are often lacking in nutritional value). Poorly controlled / uncontrolled diabetes heightens the risk of both acute and chronic complications.

In an attempt to ensure accessibility and affordability of insulin therapy to persons with diabetes, the Inflation Reduction Act of 2022, in part, ensures that persons with diabetes on Medicare pay no more than $35 for a month’s supply of insulin product under their prescription drug coverage. Similar drug coverage benefits were also extended to many state-based insurance plans. (36)

In addition, most Medicaid insurance plans, as well as private insurance companies, have now enacted reduced insulin costs/cost-sharing programs. Finally, for patients with no insulin cost benefits, many national insurance providers offer free/reduced-cost insulin through their patient assistance program. For a comprehensive list of these resources, please see the following website link (American Diabetes Association): https://diabetes.org/tools-resources/affordable-insulin

Research: Insulin Delivery Systems

With the creation of advanced insulin delivery /monitoring devices (insulin pumps and continuous glucose monitoring devices), the person with diabetes is afforded a more streamlined process to control their chronic medical condition. Most patients using such devices report better glucose control {“time in range”}, meaning the time their blood glucose levels remained in an acceptable range, ease of portability (of supplies), increased comfort (no more finger sticks), and decreased rates of anxiety, depression, and distress.

The following website links represent various insulin delivery devices. Consider creating a resource book containing various delivery devices for your specific unit (or hospital organization). Many have 24/7 customer service representatives available if you need to troubleshoot a device suspected of malfunctioning or require additional staff/patient educational resources.

This list contains a variety of websites, but is not all-inclusive. If you are caring for a patient with an insulin delivery device in place, please contact that specific company for more directions on its usage, removal, replacement parts, and more.

Examples of insulin delivery devices:

• Makers of the MiniMed 780G System and the MiniMed 630G system: https://www.medtronic.com/us-en/healthcare-professionals/products/diabetes/insulin-pump-systems.html
• Makers of the Omnipod 5 and the Omnipod DASH Insulin Management System: https://www.omnipod.com/
• Quick overview of various insulin pumps currently on the market: https://consumerguide.diabetes.org/collections/pumps

Case Studies

Case Study #1

A 3-year-old female child is sent by ambulance from her local pediatrician’s office with reports of increased lethargy, increased thirst and appetite, and a new onset of bedwetting (the child had stopped wearing diapers at age 2.5). Parents report that the child’s appetite appears to have increased lately, but the pediatrician noted several pounds of weight loss since the last visit.

Case Study #2

A 78-year-old female with a previous history of CVA is transferred to your facility from a local nursing home for evaluation of fever and hyperglycemia. The nursing home staff reported that the patient’s blood glucose level was 400mg/dl earlier today, and her WBC count was 14,500. Upon arrival, the patient is unresponsive, with a temperature of 102F, her glucose is 350mg/dl, with +ketones (moderate), and a urinalysis (indwelling catheter) confirms a UTI.

The patient’s past medical history includes old CVA and T2DM.

Case Study #3

A 60-year-old male presents to the Emergency Department with an Acute Myocardial Infarction.

Patient’s past medical history includes borderline hypertension and prediabetic HgbA1C 5.8.

The patient was found to have severe coronary artery disease and received Coronary Artery Bypass Graft x 3. During the immediate post-operative recovery phase, he receives insulin therapy to control glucose levels >300mg/dl. He is eventually sent home on insulin therapy, pending follow-up with his cardiologist as well as a new consultation for an endocrinologist.

At the time of discharge, the patient is adamant that he was “prediabetic and could easily control my glucose levels with diet alone”; he doesn’t understand how he is now “an insulin diabetic”.

Successful management of acute diabetic ketoacidosis requires resuscitation with intravenous fluids and insulin therapy, replacement of electrolytes, and early identification of any events (medical, surgical, and psychological) that contributed to this medical emergency. With the continued increase in the diagnosis of diabetes and ongoing challenges in healthcare costs and coverage, chronic medical conditions will continue to burden the already overwhelmed healthcare arena. By educating and empowering patients to self-manage their disease process, we can lower the risk of long-term complications and improve health outcomes worldwide.

Conclusion

The International Diabetes Federation reports that, in 2021, approximately 10.5 % of the global adult population (ages 20-79 years old) had diabetes, and that nearly 50% of this population were unaware that they were living with this chronic condition. Left untreated, the rates of long-term, nonreversible complications are quite alarming. (37) By the year 2045, it is projected that 1 in every 8 persons (approximately 12.5 %) will be living with diabetes. This will equate to an increase of 46 percent, with nearly 783 million people being affected. This single health condition will represent staggering health expenditures and increased mortality and morbidity associated rates worldwide.

Diabetic ketoacidosis continues to be a potentially life-threatening complication for persons with diabetes. DKA is also, in most cases, a highly preventable condition, with early identification and treatment. The importance of ongoing, patient-specific education to address all aspects of diabetes self-management is a key factor in lowering the occurrence of DKA. Dr William Polonsky, a licensed clinical psychologist and certified diabetes educator, is the President of the Behavioral Diabetes Institute in San Diego, California. With regards to the importance of patient education and empowerment, he said the following:

“Well-controlled diabetes is the leading cause of nothing!” Dr William Polonsky. (38)

As healthcare professionals, we have the responsibility to ensure that our patients with diabetes receive the education and ongoing support necessary to manage their specific disease process successfully. In doing so, we positively impact patient satisfaction, improve medication adherence rates, and lower the risk of long-term complications.