Hypoglycemia vs Diabetic Keto Acidosis: How to Care of Them?

NATTAYA SANONOI

Nurse Manager, Expert Level

Nursing Department, King Chulalongkorn Memorial Hospital
Bangkok, Thailand
 Area of nursing excellence

• Cardio vascular Thoracic Surgery unit

• Pre operative and Post operative care of patients
Coronary Artery Bypass Graft : CABG
Coronary artery bypass graft with Comorbidity

1. Diabetes mellitus
2. Chronic kidney disease
 Diabetes mellitus (DM)
Diabetes mellitus (DM) is a chronic metabolic disorder that disrupts
the metabolism of primary macronutrients such as proteins, fats, and
carbohydrates. DM is a well-known risk factor for cardiovascular disease
and increases the mortality rate by 2‐ to 4‐fold. DM remains a leading
cause of death worldwide and is the number one cause of kidney failure,
lower-limb amputations, and adult blindness.
(Aldhaeefi, M., Aldardeer, N. F., Alkhani, N., Alqarni, S. M., Alhammad, A. M., & Alshaya, A. I. (2022).
 Criteria for the Screening and Diagnosis of Prediabetes and Diabetes

Prediabetes Diabetes

HBA1C 5.7–6.4% (39–47 mmol/mol)* ≥6.5% (48 mmol/mol)†

Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L)* ≥126 mg/dL (7.0 mmol/L)†

140–199 mg/dL (7.8–11.0

2-hour plasma glucose during 75-g OGTT ≥200 mg/dL (11.1 mmol/L)†
mmol/L)*

Random plasma glucose — ≥200 mg/dL (11.1 mmol/L)‡

American Diabetes Association

https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022
 Effects of diabetes

Impair neutrophil Respiratory failure

Wound healing Acute kidney injury
wound Infection Myocardial infaction
Bacteremia CHF
Pneumonia Cardiac arrhythmia

(David Reyes‐Umpierrez, 2016; Vahideh Koochemeshki, 2013)

 Nursing management

• The strongest evidence supporting lifestyle intervention for diabetes

prevention in the U.S. comes from the DPP trial, which demonstrated
that intensive lifestyle intervention could reduce the risk of incident
type 2 diabetes by 58% over 3 years. Evidence suggests that there is
not an ideal percentage of calories from carbohydrate, protein, and
fat to prevent diabetes.
 ADA’s grading system uses A, B, C, or E to show the evidence
level that supports each recommendation.

A—Clear evidence from well-conducted, generalizable randomized

controlled trials that are adequately powered

B—Supportive evidence from well-conducted cohort studies

C—Supportive evidence from poorly controlled or uncontrolled studies

E—Expert consensus or clinical experience

Standards of Medical Care in Diabetes—2022” (https://doi.org/ 10.2337/dc22-SPPC).

 Improving Care and Promoting Health in Populations

Ensure treatment decisions are timely, rely on evidence-based

guidelines, include social community support, and are made

collaboratively with patients based on individual preferences,

prognoses, and comorbidities, and informed financial considerations. B

 Improving Care and Promoting Health in Populations.

Align approaches to diabetes management with the Chronic Care Model.

This model emphasizes person-centered team care, integrated long-term

treatment approaches to diabetes and comorbidities, and ongoing collaborative

communication and goal setting between all team members. A

 Improving Care and Promoting Health in Populations.

Care systems should facilitate team-based care, including those

knowledgeable and experienced in diabetes management as part of the

team and utilization of patient registries, decision support tools, and

community involvement to meet patient needs. B

 Strategies for System-Level Improvement

• Care Teams

Collaborative, multidisciplinary teams are best suited to provide

care for people with chronic conditions such as diabetes and to facilitate
patients’ self-management with emphasis on avoiding therapeutic
inertia to achieve the recommended metabolic targets. A
 Telemedicine

Telemedicine may increase access to care for people with diabetes.

Increasingly, evidence suggests that various telemedicine modalities may be

effective at reducing A1C in people with type 2 diabetes compared with or

in addition to usual care. Interactive strategies that facilitate communication

between providers and patients appear more effective.

 Behaviors and Well-Being

Successful diabetes care requires a systematic approach to supporting

patients’ behavior-change efforts, including high-quality diabetes self-
management education and support (DSMES).
• The Diabetes Prevention Program
• Delivery and Dissemination of Lifestyle Behavior Change for Diabetes
Prevention
• Nutrition
• PATIENT-CENTERED CARE GOALS
• PHARMACOLOGIC INTERVENTIONS
 The Diabetes Prevention Program
• Several major randomized controlled trials, including the Diabetes Prevention
Program (DPP)
Demonstrate that lifestyle/behavioral therapy with individualized
reduced-calorie meal plan is highly effective in preventing or delaying type 2
diabetes and improving other cardiometabolic markers (such as blood
pressure, lipids, and inflammation)
 PHARMACOLOGIC INTERVENTIONS
Recommendations
• Metformin therapy for prevention of type 2 diabetes should be considered
in adults with prediabetes, as typified by the Diabetes Prevention
Program, especially those aged 25–59 years with BMI $35 kg/m2, higher
fasting plasma glucose (e.g., $110 mg/dL), and higher A1C (e.g., $6.0%),
and in women with prior gestational diabetes mellitus. A
• Long-term use of metformin may be associated with biochemical vitamin
B12 deficiency; consider periodic measurement of vitamin B12 levels in
metformin-treated patients, especially in those with anemia or peripheral
neuropathy. B

Association, A. D. (2022)
 LIFESTYLE BEHAVIOR CHANGE FOR DIABETES PREVENTION

• Refer adults with overweight/ obesity at high risk of type 2 diabetes, as typified by the
Diabetes Prevention Program (DPP), to an intensive lifestyle behavior change program
consistent with the DPP to achieve and maintain 7% loss of initial body weight, and
increase moderate-intensity physical activity (such as brisk walking) to at least 150 min/
week. A
• A variety of eating patterns can be considered to prevent diabetes in individuals with
prediabetes. B
• Given the cost-effectiveness of lifestyle behavior modification programs for diabetes
prevention, such diabetes prevention programs should be offered to patients. A Diabetes
prevention programs should be covered by third-party payers and inconsistencies in access
should be addressed.
• Based on patient preference, certified technology-assisted diabetes prevention programs
may be effective in preventing type 2 diabetes and should be considered. B

Association, A. D. (2022)
 The Hospital Management

• The hospital management of hypoglycaemia in adults with diabetes

mellitus

• The management of diabetic ketoacidosis in adults

• Most hypoglycaemia occurs in people admitted to hospital for another
reason, it is much less common for it to be the primary cause of admission.
Capillary blood glucose testing on admission demonstrated hypoglycaemia
in 9.5% of PWDiH although only a minority of these had hypoglycaemia
mentioned in the discharge summary or given as the principal cause of
admission. Hypoglycaemia was given as the cause of admission for 5% of
admissions for people with T1DM and 1.5% of admissions for people
withT2DM.
 Nurse Play Role

• Social determinants of health play a role in diabetes management and

outcomes, including potentially life-threatening complications of severe
hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic
hyperosmolar state (HHS). Although several person-level socioeconomic
factors have been associated with these complications, the implications of
area-level socioeconomic deprivation are unknown.
 What is hypoglycemia?
• Hypoglycemia is defined as blood glucose <3.5 mmol/L. (63 mg/dl)
• However, below 2.5 mmol/L (45 mg/dl) is considered pathological requiring investigation.
• A blood glucose of 4.0 mmol/L (72 mg/dl) should be the lowest acceptable blood
glucose level for people with diabetes.
Association, A. D. (2022)

Hypoglycaemia is a serious condition and should be treated as an emergency regardless of

level of conciousness. Hypoglycaemia is defined as blood sugar glucose of <4.0 mmol/L
(72 mg/dl) (if not <4.0mmol/L but symptomatic give a small carbohydrate snack for
symptom relief) Joint British Diabetes Societies for inpatients Care (JBDS), 2022
 Risk factors for hypoglycemia
• Tight glycemic control.

• Malabsorption.

• Injection into lipohypertrophy sites.

• Alcohol.

• Insulin prescription error (notable in hospitalised patients).

• Long duration of diabetes.

• Renal dialysis.

• Drug interactions between hypoglycaemic agents - eg, quinine, selective serotonin reuptake inhibitors (SSRIs).

• Impaired renal function.

• Lack of anti-insulin hormone function - eg, Addison's disease, hypothyroidism

 Risk factors for hypoglycemia
• Blocked/displaced feeding tube
• Change in feed regimen
• Enteral feed discontinued
• TPN or IV glucose discontinued
• Diabetes medication administered at an inappropriate time to feed
• Changes in medication that cause hyperglycaemia e.g. steroid therapy
reduced/stopped
• Feed intolerance
• Vomiting
• Deterioration in renal function
• Severe hepatic dysfunction
 Causes of hypoglycemia
• Lifestyle issues
• Unusual or unplanned physical activity. Exercise increases the body’s sensitivity to insulin, lowering blood glucose more
than usual unless the dose is reduced or additional carbohydrate is consumed to compensate for this
• Excessive alcohol, especially when combined with increased physical activity. People’s sensitivity to the effects of
alcohol will vary, depending on whether they consume alcohol regularly
• Frequent low blood glucose levels
• Hypoglycemia symptoms may be dulled or lost if blood glucose levels are frequently below target. This increases the
risk of severe hypoglycemia as the person with diabetes gets few or no warning symptoms of their blood glucose
dropping and is unable to treat it in time to avoid coma
• Reduced renal function
• Insulin and oral hypoglycemic agents need to be taken regularly as they are eliminated from the body by the kidneys.
Where renal function is deteriorating, medications can accumulate, leading to a gradual increase in the frequency of
hypoglycemic episodes
• Losing weight, intentionally or through loss of appetite or illness, means less insulin is required to maintain normal
blood glucose. If the dose of sulphonylureas or insulin is not adjusted, the patient is at risk of hypoglycemia
Risk Factors for Hypoglycemia

Joint British Diabetes Societies for inpatients Care (JBDS), 2022

 Causes of hypoglycemia
• The insulin action did not match the expected rise in blood glucose after a meal

• This can occur if a meal is delayed after an insulin injection or sulphonylurea has been given and
has started to be effective

• The carbohydrate portion of the meal is smaller than required by the dose of insulin given

• The insulin works too rapidly because it was injected into a muscle instead of subcutaneous fat

• Too high a dose of insulin or oral hypoglycemic agents was given

• The wrong insulin was given. If rapid-acting insulin is given instead of long-acting insulin, as the
large dose at bedtime without food, sudden hypoglycemia will occur within an hour or so at the
beginning of the night
 The diagnosis of hypoglycaemia

• The diagnosis of hypoglycaemia rests on three criteria (Whipple's

triad) of plasma hypoglycaemia, symptoms attributable to a low
blood sugar level and resolution of symptoms with correction of the
hypoglycaemia. (Causes, Symptoms, and Treatment).
 Hypoglycaemia symptoms

• Neurological manifestations of hypoglycemia include coma,

convulsions, transient hemiparesis and stroke, while reduced
consciousness and cognitive dysfunction may cause accidents and
injuries. Cardiac events may be precipitated - eg, arrhythmias,
myocardial ischaemia and cardiac failure.
Signs and symptoms of hypoglycemia

Symptoms include:

• Sweating
• Shaking
• Trembling
• Feeling hungry
• Looking pale
• Feeling anxious
• Palpitations
• Tachycardia
 Later signs and symptoms
The neuroglycopenic stage, where blood glucose is below 2.8mmol/L
include:

• Blurred vision
• Difficulty concentrating
• Slurring of speech
• Confusion
• Change in behaviour (such as being aggressive, acting as if drunk)
• Convulsions
• Coma
 Nursing management

• Ongoing management should be guided by the assessment of overall

health status, diabetes complications, CV risk, hypoglycemia risk, and
shared decision-making to set therapeutic goals. B
 The goals of treatment for diabetes

prevent or delay complications and optimize quality of life.

Evidence for the Benefits

Studies have found that DSMES is associated with improved diabetes

knowledge and self-care behaviors, lower A1C, lower self-reported weight,
improved quality of life, reduced all-cause mortality risk, positive coping

behaviors, and reduced health care costs. Better outcomes were reported for
DSMES interventions that were >10 hours over the course of 6–12 months
 How to manage hypoglycemia

• Hypoglycemia affects the quality of life of patients with diabetes and can be fatal
• 5 key points
• Hypoglycemia is common and can occur in people with either type 1 or type 2 diabetes who use insulin or
oral medications that stimulate insulin production
• Maintaining well-controlled blood glucose levels can reduce the risk of diabetes complications
• Hypo-glycemia is mild if people can treat it themselves, and severe if they require the help of a third party
• Some patients have “hypoglycemia unawareness” – they have no symptoms and may lose consciousness
without warning
• Anyone using a treatment that can cause hypoglycaemia should be warned about this risk and when it
can occur
 Carbohydrate Treatments

Examples of 15-20g rapid-acting carbohydrate treatments for hypoglycaemia

include:
• 150ml non-diet Coca-Cola (small tin)
• 100ml of Lucozade Original
• 5-6 dextrose tablets
• Four GlucoTabs
• 200ml smooth orange juice (small carton)
 The symptoms are mild and feel good

Patient was conscious, orientated and able to swallow

• Essentially, a quick-acting carbohydrate needs to be given, followed by a longer-

acting carbohydrate.

• ½ cup sweetened juice (2 tablespoons of concentrated sweetened juice mixed

with 120 cc of water)

Source: https://www.ram-hosp.co.th/news_detail/1699© Ramkhamhaeng Hospital - Medical specialists in all fields

 Quite severe symptoms but feel good

• ½ glass of freshly squeezed fruit juice without added sugar

• 2 candies or 2 sugar cubes

• 3 teaspoons of sugar, 3 teaspoons of honey

Source: https://www.ram-hosp.co.th/news_detail/1699© Ramkhamhaeng Hospital - Medical specialists in all fields

Algorithm for the Management of Hypoglycaemia in Adults with Diabetes in Hospital

Retrieved from www.diabetes.org.uk/joint-british-diabetes-society, 2022

 After acute treatment

• Consideration should be given to whether the hypoglycaemia is likely

to be prolonged, i.e. as a result of long-acting insulin or sulfonylurea
therapy; these PWDiH may require a continuous infusion of glucose
to maintain blood glucose levels.
• Regular blood glucose monitoring enables detection of asymptomatic
biochemical hypoglycaemia.
• For the majority of people with diabetes in hospital, a blood glucose
between 4.0-6.0mmol/L (72-108 mg/dl)
Adults who are conscious, orientated and able to swallow

1. Quickly check the following. Don’t spend too much time on this,
particularly if the person is otherwise well

a. Airway
b. Breathing
c. Circulation
d. Disability (including Glasgow Coma Scale (GCS) and blood glucose)
e. Exposure (including temperature)
 Adults who are conscious, orientated and able to swallow
2. If the person with diabetes in hospital (PWDiH) has an insulin infusion in situ, stop
3. Give 15-20g rapid-acting carbohydrate of the person with diabetes in hospital’s PWDiH’s
4. Repeat capillary blood glucose measurement 10-15 minutes later. If it is still less than
4.0mmol/L (74 mg/dl)
5. If blood glucose remains less than 4.0mmol/L after 30-45 minutes or 3 treatment cycles,
call for medical assistance. If agreed locally, glucagon (and IV glucose) may be given
without prescription in an emergency for the purpose of saving a life or via a Patient
Group Directive.
6. Repeat capillary blood glucose measurement 10 minutes later. If it is still less than
4.0mmol/L
7. Once blood glucose is above 4.0mmol/L(72 mg/dl) and the PWDiH has recovered, give a
longacting carbohydrate snack (20g)
 Nursing management

• The blood glucose should be checked after about five minutes and the
rapid-acting treatment should be repeated every 5-10 minutes until
the blood glucose has risen to 4mmol/L or greater (or, if no blood
glucose monitoring is available, until symptoms have resolved). The
person should then eat some starchy carbohydrate if they are not due
to eat a meal within the next hour.
 Prevention
• Anyone using a treatment that can cause hypoglycemia should be warned about this
risk and the circumstances in which it can occur. They should be informed about the
signs and symptoms, advised to carry glucose with them at all times, and given
instructions about treatments to alleviate hypoglycemia. People should be
questioned on their understanding of hypoglycemia as part of their annual diabetes
review, and information gained regarding any episodes of, for example, dizziness or
sweating that may be unrecognised hypoglycemia.

• There are several oral and injectable treatments for blood glucose control that do not
stimulate insulin production as sulphoylureas do and, therefore, have a low risk of
inducing hypoglycemia. These include pioglitazone, DPP1V inhibitors and GLP-1
mimetics. These alternative agents may be preferable, especially in people who drive
regularly or older people in whom an episode of hypoglycemia can have particularly
devastating effects
 Mistakes from the medical team

• Unfortunately, hypoglycemia can occur through mistakes made by

health professionals giving the incorrect dose. The National Patient
Safety Agency (2010) issued an alert and e-learning package about
the safe use of insulin to highlight common mistakes made through
incorrect prescribing of insulin dose. For example, the use of “u”
instead of “units” resulted in one case where a person was injected
with 40 units when the dose was written as 4u. The e-learning about
safe use of insulin can be accessed
 DKA Process and DKA Emergencies

• Diabetic ketoacidosis is an acute life-threatening

complication of diabetes mellitus. With appropriate
treatments, diabetic ketoacidosis patients are
expected to make a full recovery within 24 hours.

(Diabetic ketoacidosis. Nat Rev Dis Primers, 2020 )

 Definition of diabetic ketoacidosis

• Ketonaemia >3.0 mmol/L or significant ketonuria (more than 2+ on

standard urine sticks)

• Blood glucose >11.0 mmol/L or known diabetes mellitus

• Bicarbonate (HCO 3−) <15.0 mmol/L and/or venous pH <7.3

 Markers of severity in diabetic ketoacidosis
The presence of one or more of the following may indicate severe diabetic ketoacidosis.
Patient requires senior review with consideration of transfer to high-dependency unit.
> Blood ketones over 6 mmol/L
> Bicarbonate level below 5 mmol/L
> Venous/arterial pH below 7.0
> Hypokalaemia on admission (under 3.5 mmol/L)
> Glasgow coma score less than 12 or abnormal alert, verbal, pain,
unresponsive (AVPU) scale
> Oxygen saturation below 92% on air (assuming normal baseline respiratory
function)
> Systolic blood pressure below 90 mmHg
> Pulse over 100 or below 60 bpm
> Anion gap above 16 [Anion gap = (Na++ K+) − (Cl−+ HCO 3− )]
 Characteristics of hyperglycemic crises

• The records of 2233 hospitalization episodes related to diabetes mellitus

were review, the prevalence of hyperglycemic crises was 2%, half of the
events were diabetic ketoacidosis and 57% of the events occurred in
people with type 2 diabetes mellitus, 32% of the events were precipitated
by an infection and 27% by and inadequate therapy. The average hospital
length of stay was 14 ± 3 days and the mortality rate 2.27%.

Builes-Montao CE, et al, 2018

 Classification of DKA in adults and children
Variables Mild Moderate Severe
Blood glucose Adult: >13.9 mmol/L (> 250 mg/dL)
Children: >11 mmol/L (> 200 mg/dL)
Vitals (Pulse, SBP, SpO2) P < 100 or > 60 bpm, SBP >100; P < 100 or > 60 bpm, BP >100; P > 100 or < 60; BP <90;
SpO2 > 95% SpO2 > 95% SpO2 < 92%
Anion gap (mEq/L; mmol/L) >10 >12 >16

Dehydration 5% > 5 to 7% >7 to ≥10%

a
Venous pH Adult: 7.24 to 7.3 Adult: 7.00 to <7.24 Adult: <7.00
Children: 7.2 to 7.29 Children: 7.1 to 7.19 Children: <7.1
Serum osmolality mOsm/kg Variable Variable Variable

Mental status Alert Alert/ drowsy Stupor/ coma

b
Venous HCO3 Adult: 15 to 18 Adult: 10 to <15 Adult: < 10
(mEq/L, mmol/L) Children: < 15 Children: < 10 Children: < 5
Serum/capillary ≥ 3.8 to <6 in adults; ≥ 3 to <6 ≥ 3.8 to <6 in adults; ≥ 3 to <6 ≥ 6 both adult and children
c
BOHB (mmol/L) in children in children
d
Urine STICKS-AcAc > 2+ in urine sticks > 2+ in urine sticks > 2+ in urine sticks
GCS 14–15 14–15 < 12
 Diabetic ketoacidosis: update on management

• DKA occurs due to the consequence of an absolute or relative lack of

insulin and concomitant elevation of counter-regulatory hormones, usually

resulting in the triad of hyperglycemia, metabolic acidosis, and ketosis

(Eledrisi MS, Elzouki A-N. , 2020)

The management of diabetic ketoacidosis in adults—An updated guideline from the Joint British Diabetes Society for Inpatient Care

Diabetic Medicine, Volume: 39, Issue: 6, First published: 27 February 2022, DOI: (10.1111/dme.14788)
The management of diabetic ketoacidosis in adults—An updated guideline from the Joint British
Diabetes Society for Inpatient Care

Diabetic Medicine, Volume: 39, Issue: 6, First published: 27 February 2022, DOI: (10.1111/dme.14788)
 Key components of DKA management

• The most important initial therapeutic intervention in DKA is

• appropriate fluid replacement followed by insulin administration.
• The main aims for fluid replacement are:
> restoration of circulatory volume
> clearance of ketones
> correction of electrolyte imbalance
 Insulin Management

• Insulin should be administered intravenously and given at a fixed rate using

a weight-based formula: 0.1 units per kilogram body weight per hour.

Nursing Role, to estimate the patient’s weightweight.

Fixed rate intravenous insulin infusion (FRIII) not only reduces blood glucose
levels, but just as importantly, suppresses further ketogenesis, as well as
correcting the electrolyte disturbance
 Biochemical Monitoring

Frequent biochemical monitoring is required: glucose, capillary ketones,

venous pH, and serum potassium. It is not necessary to use arterial blood
to assess acid-base status; venous sampling is sufficient as the difference
between arterial and venous pH/HCO 3 is not significant enough to
influence diagnosis or management of DKA
 Metabolic treatment targets
Reduction of the blood ketone concentration by 0.5 mmol/L/hour.
> Increase the venous bicarbonate by 3.0 mmol/L/hour.
> Reduce capillary blood glucose by 3.0 mmol/L/hour.
> Maintain potassium between 4.0 and 5.5 mmol/L.

If these targets are not achieved, then the FRIII rate should be increased. As
clearing ketones is as important as normalizing blood glucose, it is often
necessary to give intravenous 10% dextrose, to avoid hypoglycaemia and allow
continued FRIII to suppress ketogenesis; start 10% dextrose when the blood
glucose falls below 14.0 mmol/L. It is important to continue 0.9% sodium chloride
solution to correct circulatory volume, ie it is quite often necessary to infuse
these solutions concurrently.
 Effect of CABG

1. Surgical trauma
2. CPB Cardiopulmonary bypass
3. Hypothermia
4. Higher level of inflammatory response
5. Pulmonary and pericardial perfusion
 Resolution of DKA

• > pH >7.3 units

• > Bicarbonate >15.0 mmol/L

• > Blood ketone level <0.6 mmol/L

 Interpreting capillary ketone levels

• <0.6 mmol/L - normal blood ketone value

• > 0.6 to 1.5 mmol/L - more ketones being produced than
normal; re-test in a few hours
• > 1.6 to 3.0 mmol/L - a high level of ketones; risk of ketoacidosis
• >3.0 mmol/L – consistent with diabetic ketoacidosis
 What has changed in diabetic ketoacidosis management
over the past decade?

• Measurement of capillary (not urinary) ketones

• Using capillary ketone level to guide treatment rather than capillary glucose
• Measuring venous (not arterial) pH and bicarbonate
• Using weight-based fixed rate intravenous insulin infusion(FRIII) instead of
‘sliding scales’
• Monitoring of electrolytes on blood gas analyser with intermittent
laboratory confirmation
• Continuing long acting basal insulin analogues alongside FRIII
 Troubleshooting
If DKA is not resolving
- check cannula patency and placement. Confirm the correct rate of
intravenous infusions (FRIII and fluids) has been administered.
- Look again for concomitant pathology, eg intraabdominal sepsis,
myocardial infarction.
- Consider if insulin resistanceis likely, eg obesity, concurrent steroid
therapy; increase rate of FRIII.
- Reassess fluid status, and consider increasing rate of intravenous
(IV) fluids.
 Continuing long acting subcutaneous insulin

• The patient’s basal (long acting) analogue insulin (eg Levemir/

detemir, Lantus/glargine, Tresiba/degludec) should be continued
alongside the FRIII to prevent rebound hyperglycaemia when IV
treatment is stopped. Individuals with a new diagnosis of T1DM
presenting with DKA should be started on basal insulin as soon
as possible, and IV insulin continued until there is some basal
subcutaneous (SC) insulin on board. For conversion to SC insulin in
newly diagnosed patients, seek specialist input.
 DKA has resolved

• DKA has resolved and patient is able to eat and drink, SC insulin
therapy can be restarted. It is important that the intravenous insulin
infusion is not discontinued until at least 30–60 minutes after the
administration of the SC insulin dose taken with a meal.

• DKA has resolved but patient is not yet ready to eat and drink, then
switch to a variable rate insulin infusion and IV fluids according to
fluid status

Temesgen D, Miskir Y, Dessie G, Nuru A, Tesema BB, Azmeraw M, Teym A, Dagne M, 2022
 Best practice

• review of usual glycaemic control

• review of injection technique/blood glucose

monitoring/equipment/sites

• contact telephone numbers for the diabetes specialist team

including out of hours

Compare to No DM& DM

1. Increase rate of complication

2. Infection
3. Mortality
4. Increase length of stay

(Daniel Hertzberg, 2015; Mehmet Oezkur, 2015)

 Risk factor effect to CABG

1. Hyperglycemia 60-90% poor clinical outcome

2. Mortality rate 70% ( if blood sugar > 180 mg% )

3. LOS

4. Arrhythmia

5. Stroke

6. AKI

(Daniel Hertzberg, 2015; Mehmet Oezkur, 2015)

 Blood Sugar Control

With DM Without DM

100-140 mg% 141-180 mg%

Intensive Conservative 100-140 mg% 141-180 mg%

(Vahideh Koochemeshki, 2013)

 Complication had higher level of

1. Cortisol, h5CRT,TL6 and Oxidative stress makers compared to

those without complication
2. DM & DM non significance

treatment Intensive, conservative, insulin treatment

3. Cardiac patient with or without hyperglycemia

hyperglycemia poor clinical outcome

(Vahideh Koochemeshki, 2013)

 Observe Compilcation

Inflammatory marker cortisol in patient with

complication ( Pre-op)

Inflammatory and oxidative stress maker, Cortisol,

CRP, Interlukin in daqy3, Higher from baseline,
retureing to baseline in 30 day

(Vahideh Koochemeshki, 2013)

 CABG
DM

Stress H.( Steriod, Glugacon,Adrenaline )

Hyperglycemia

Pro-in flammatory and oxidative state ( Tumor necrosis

factor-alpha TNF-α , Interluekin IL-1, C-reative Protien)

High risk complication

ICU control BS= 100-140 mg%

Vs Conservative BS= 141-180 mg%
 Result of hyperglycemia

Induce monocyte

Pro inflammatory
Hyperglycemia Oxydative state

Insulin resistance

Vascular
dysfunction

Stroke Arrhythmia
 DM

AF CABG ( CPB)
SIRs

Hypo-perfusion Hemodilution Hypothermia

Cortisol
Acute MI
Hyperglycemia
AKI

Stroke Venticular failure Infection

Mortality
 CABG

If CAD is too severe and

cannot be controlled by
optimal medication
treatment or percutaneous
coronary intervention
(PCI), treatment must be
based on coronary artery
bypass graft (CABG).
A major surgery for CAD

Depression impaired
cardiac status
Pain

Self-
efficacy Functional
status
 Gap of care

CABG 
readmission

Operation wound infection

 Surgical
wound care

Food for patients

Activity daily
high blood
living pressure
Patient
advice

Precautions Operation
after wound care
operation
Multidisciplinary Team

Patient Advice
• Surgical wound care
• food for patients HT, DM, DLP

• Precautions after surgery

• Activity daily living

Patients outcome
 CABG readmission risk

• …………....Age ≥ 65 ปี

• ……………. Comobidility
• ...............Congestive heart fuilure
• ……………. Creatinin ≥ 1.3 mg/dl
• …………….. Fatigued
• …………….. Heart palpitations
• ……………..Cardiac Arrhythmia
• …………….Blood sugar ≥ 200 mg%
• ……………. Surgical wound, red, oozing
• …………….. Swollen legs, swollen ankles
• ……………. Taking more than 5 oral medications
• ……………. Patients are anxious about taking care of themselves when they go home.
• ............... other..............................................................................
 Telehealth Program

Week 1 - Patients sent data on blood pressure, pulse rate and

bodyweight once before meals in the mornings.
เอกสารหมายเลข 2
Week 2 - Patients sent data on blood pressure and pulse
rate once a day in the mornings.
Weeks 3 and 4 - Patients record blood pressure and pulse
rate 1 time a day. Nurse followed up by telephone once a week.
Operation wound
 Nursing role
•Independent Intervention
•Interdependent Intervention
•dependent Intervention
 Using Nursing Process in Tele clinic
Nursing process Action

Assessment Assessment before discharge from the hospital

Diagnosis Identified patient risk for readmission

Planning Monitoring on patients risk

Day 1, 3, 7, 14, 21, 28
Implementation Nursing consult on health ploblem

Evaluation Evaluated on patients health status

CABG D/C Day 1
EMR Record
Doctor Response
Early identification of patients’health
problem and management was very
important and key to successful