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Diabetes – Summer 2012
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Diabetes mellitus is "growing to epidemic proportions," as stated by Bardsley and Want in the first article in this series. It has become a disease of increasing concern in the 21st century. It is an expanding problem in the United States, as with increasing affluence, people are eating more, choosing the wrong kind of foods, and becoming less active. The Editorial Board of Critical Care Nursing Quarterly felt that including articles about diabetes mellitus and patient care in the critical care settings was vital because of the role diabetes mellitus plays as a comorbidity in critical illness.
This is a disease that affects all body systems and organs. It is noted, and now well documented, that control of blood glucose levels not only reduces the risks of neuropathy, nephropathy, retinopathy, and to a lesser extent, but just as important, cardiovascular disease, but also, as many authors emphasized, allows individuals to heal faster and have an improved quality of life. The articles that follow elucidate on many aspects related to the blockage of oxygen to the cells and their demise due to the elevated blood glucose levels. And the good news is that treatments, education, and medications are making what seemed almost impossible to achieve, the normalization of blood glucose levels, tolerable and safe for the individual patient.
The "Overview of Diabetes" orients the reader to the facts and figures of diabetes in this country. One is made aware that the updates for diagnostic criteria for diabetes are more realistically allowing individuals to be diagnosed earlier and to begin treatment aimed at preventing the multitude of complications that accompany high blood sugars. The lower blood glucose value of 100 mg/dL is now used to screen those who might have prediabetes (historically termed impaired glucose tolerance). It is especially helpful in identifying those who will have diabetes but are yet to be diagnosed. Whether at home or in the critical care unit, the emphasis is on glucose control in order to have the best outcomes possible.
What all is happening and why? Richard Guthrie introduces the updated information on the pathophysiology of the disease. There is an appreciation not only for what is going on in type 1 diabetes (historically insulin-dependent diabetes; juvenile diabetes, but also found in adults), but also for what is going on in the insulin-resistant type of diabetes (type 2 diabetes-historically non-insulin-dependent diabetes; adult-type diabetes, but also found in children) found in the predominant number of individuals-a syndrome that often develops from or contributes to the metabolic syndrome of hyperglycemia, hyperlipidemia, hypertension, hyperinsulinism, and obesity.
Too many times in the past, elevated blood glucose levels in the critically ill or surgical patient were attributed to be occurring because of the stressor associated with the immediate health situation. But this is not true. If the body cannot tolerate such stressors, then there is something wrong. Monica DiNardo addresses how important blood glucose control is in relation to limiting adverse outcomes in the acutely ill and surgicle person in her article, "The Importance of Normoglycemia in Critically Ill Patients." A number of studies have found that an acceleration in problems appears with the blood glucose levels rising up to 150 mg/dL or more. Traditionally, these levels have been kept at 200 mg/dL or higher in order to prevent hypoglycemia. Fear of hypoglycemia has many times overridden good judgment and logic. If the body is imbalanced, the outcome is bound to be less than favorable. The author notes that not only understanding but also the utilization of resources are necessary to provide the quality and type of care needed in critical care practice.
Dr Mokshagundam follows this article on critical illness by addressing, "Perioperative Management of Diabetes Mellitus." He supports the conclusion reached by the other authors that blood glucose control in necessary, even in the operating room and especially before the surgical procedure begins. He notes the continued need of a team approach and the use of "effective regimens" to be carried out in the perioperative and postoperative periods. He introduces a methodology of sliding scale adjustments, which are commonly used, vs an approach that is frequently recognized as being more physiological and more individualized. This second approach is one based on the person's history and body mass. Most important is the recognition that the normalization of blood sugars is correlated with the best outcomes.
Technology is becoming increasingly useful in this field. Point-of-Care testing for diabetes management, the focus of Blake and Nathan's article, is a term that needs to become part of the diabetes vocabulary. More and more devices are made available so that immediate results may be used to make logical judgments. These include everything from the blood sugar monitors to the continuous monitoring devices that can determine variations in blood glucose levels over a 72-hour period of time. The comparison to laboratory machine testing notes that for these other devices to be considered efficacious, they must meet stringent criteria so that few, if any, negative results arise. Confidence is gradually increasing and so the health professionals involved "are willing" to keep a patient on basal insulin through the use of an insulin pump or intravenous drip (or long-acting insulin for a basal injection) during a procedure. Insulin pumps with corresponding glucose monitors allow the comfort level of the professionals to be even more secure.
There are certain clinical issues in the care of the critically ill patient that Langdon and Shriver address. Again, the emphasis is on tight glucose control "to ensure positive outcomes." Increased risks for infection are heightened when the blood glucose levels are elevated. Other physiological changes or abnormal histories are noted to influence and challenge the critical care team. If a person is elderly or if kidney shutdown occurs, the insulin fails to release from the body through its usual routes, which may result in severe hypoglycemia on doses that, at home, had been quite useful. Whether using the individualized approach or the sliding scale, emphasis should be on the need for careful monitoring vs the immediate need of overall control.
Insulin pumps have become more popular, but often they are "new" to the hospital setting. Scott Lee brings the audience up-to-date by including not only useful information but also controversial issues and the concerns of staff and patients. There are different considerations for insulin drip, insulin, or restarting the pump. The transition from the use of intravenous drip insulin, injections of insulin, or the pump for surgery or when the injections or pump changes when the patient is in diabetic ketoacidosis, is important for the understanding of the blood glucose level response in such a specific situation. The variety of pumps available, although only 4 major brands at this writing, is also confusing for the health professional and written protocols or at least available manuals are a must.
The team approach and the variety of resources have been mentioned by almost every author. Robyn Pollom focuses on the "Utilization of a Multidisciplinary Team for Inpatient Diabetes Care." She notes an important fact that education is most important and plans for such education must begin at the time of admission even though a particular patient might not be in a state to tolerate this input early in the course of hospitalization. A community hospital model is shared, giving guidance to others as to what may be done and how.
A most important part of this team is the Certified Diabetes Educator and the availability of a certified insulin pump trainer who may be one and the same. With her repetition of some information, Amy Hess-Fischl re-emphasizes the need for biochemical normalization of all processes through the guidelines for sick days, perioperative management, and postoperative care, whether for illness or routine or emergency surgery. Education is again a strong component in the direction of care. The more commonly used carbohydrate (CHO) counting (whether by points, 1 CHO point equals 15 g of carbohydrate, or just by counting grams of CHO); (recognize that other systems such as the Exchange System, the Calorie Point System [75 calories equal 1 point], or the Total Available Glucose System may be the method used by the patient) is reviewed in this article along with information and tips on the use of pump therapy. The health professional using CHO counting needs to recognize that protein (7 g of protein is considered 1/2 a CHO count) and fat must also be considered. She appropriately includes the timing and amounts of food and medication as issues to consider "once the patient resumes eating." Close cooperation with the dietary service and the patient caregivers is a must.
Then, it is most appropriate that this series of articles ends with one by Martha Funnell. Her contributions to patient empowerment have aided many health professionals and assisted them in the knowledge that they are not all things to all people. Teaching and supporting the patient with diabetes and the family allows the greater possibility of controlled blood glucose levels to be found when at home as well as when in the hospital. Each person has his or her own ability in participating in the healthcare system. Aiding that person to find his/her own ability and expand on it allows for greater prevention of problems and more satisfactory outcomes. Preparing individuals for critical care and participation in care once the crisis is over promotes self-confidence with the recognition that the health professional cannot be with the patient 24 hours a day once the person leaves the hospital.
The challenge is there. Information is shared. Precautions are noted. The critical care nurse is able to glean valuable lessons from the articles presented. It is possible that the information herein may become out-of-date in a few years since the field of diabetes has advanced so rapidly in recent years. All in all, the basis for increased understanding for the health professional and especially for the critical care nurse is available and it is hoped that all individuals will continue to read, research, and practice the quality of care recommended in these articles.
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