- Email: [email protected]
Insulin-Dependent Diabetes
JULY 1991, VOL 54, NO 1
AORN JOURNAL
Insulin-Dependent Diabetes ITS EFFECT ON THE SURGICAL PATIENT Juliette U. Kelly, RN; Timothy J. Kelly, MD
T
he patient with insulin-dependent diabetes mellitus (IDDM) presents a challenge to the surgical and nursing staff. In addition to providing general perioperative care, the staff must administer glucose and insulin to maintain serum glucose levels within a delicate range. With appropriate knowledge, the staff can assist the patient in maintaining metabolic stability during this challenging time.
P a thophysiology
I
nsulin-dependent diabetes mellitus is a chronic illness for which there is no known cure. Also referred to as type I diabetes, IDDM occurs annually in 15 of 100,000 people under 20 years of age. Although often considered to be a disease that primarily affects children, IDDM also occurs each year in five of 100,000 people over 20 years of age.’ The pathology of this disorder lies in the failure of the pancreatic beta cells to produce insulin. Consequently, exogenous insulin is necessary to maintain the body in a normoglycemic state. Insulin is required for the passage of glucose through the cell wall. Without adequate insulin, the body is unable to metabolize glucose for energy. The body compensates by breaking down fats, which produces byproducts known as ketones. In large amounts, ketones can cause metabolic acidosis. In diabetics, this is referred to as diabetic ketoacidosis (DKA). The symptoms of DKA are polyuria, polydipsia, hyperventilation, dehydration, fruity breath odor, abdominal pain, and altered con-
sciousness ranging from lethargy to coma. Diabetic ketoacidosis is a medical emergency that requires intensive treatment. When diagnosed early, it is a reversible condition. Long-term complications of diabetes include macrovascular disease, as well as microvascular disorders (ie, nephropathy, retinopathy, autonomic and peripheral neuropathy). Microvascular complications occur more frequently in individuals with histories of poor metabolic control. Treatment of vascular complications may include surgical intervention.
Znsulin Therapy
T
reatment for the IDDM patient includes diet, exercise, and insulin administration. The physician specifies a diet in accordance with the patient’s growth needs and
Juliette U.Kelly, RN,MS, CPNP, is the clinical nurse specialist for pediatric diabetes, James Whitcomb Riley Hospital f o r Children, Indianapolis. She received her bachelor of science degree in nursing f r o m D’Youville College in Buffalo, NY, and her master of science degree in pediatric nursing f r o m University of Michigan, Ann Arbor. Timothy J . Kelly, MD, is a resident in the Department of Otolaryngology/Head and Neck Surgery at Indiana University Medical Center, Indianapolis. He earned his medical degree at University of Michigan, Ann Arbor. 61
JULY 1991, VOL 54, NO I
AORN JOURNAL
Preoperative patients with autonomic neuropathy can have impaired responses to hypoxia and are susceptible to the depressant effects of medications.
activity level. Physical activity lowers blood glucose, therefore, exercise is advantageous in maintaining good metabolic control. The physician prescribes insulin on an individual basis. The most traditional regimen involves two injections per day. Generally, each injection is a combination of short-acting insulin with either intermediate- or long-acting insulin. Meals and snacks are required at specific times throughout the day to coincide with the peak action and duration of the insulin. It is difficult to maintain adequate control of blood glucose levels with regimens involving less than two injections per day. Flexible regimens that do not require rigid schedules for meals and snacks can be attained by using long-acting insulin with a minimal peak, such as beef Ultralente, administered once per day. At mealtime, injections of shortacting insulin can be administered based on glucose levels (sometimes referred to as a sliding-scale regimen). Another option is the insulin pump, which provides a continuous infusion of subcutaneous insulin. The time action of subcutaneous insulin varies with the species (ie, human versus animal) and type of insulin. In general, human insulin has a quicker onset, peaks earlier, and has a shorter duration than pork or beef insulins. Short-acting insulin (ie, regular or Semilente) has an onset of 30 minutes to two hours, peaks at two to four hours, and lasts six to eight hours. Intermediate insulin (ie, Lente or NPH) has an onset of two to six hours, peaks at four to 12 hours. and can last up to 24 hours. Long-acting insulin (ie, Ultralente) has a usual onset of six to 12 hours and a duration of 18 to 36 hours. Animal Ultralente takes effect very gradually with no apparent peak, while human Ultralente peaks at 10 to 14 hours. Time action of insulin also varies with the site of administration. 62
Insulin absorbs best from the least utilized sites.2
Preoperative Considerations
A
s a stressor, surgery elicits the release of a number of stress-adaptive hor.mones. Catecholamines, cortisol, growth hormone, and glucagon cause a rise in plasma glucose and inhibit the tissue sensitivity to insulin. Without therapeutic intervention, hyperglycemia may cause osmotic diuresis, electrolyte imbalances, and k e t o a c i d o ~ i s . ~ Hyperglycemia also may suppress leukocyte phagocytosis and antibody responses.” Elective surgery. When elective surgery is planned, the patient should be in good metabolic control with blood glucose values between 120 and 220 mg/dL. The patient also should be in a nonketotic state, which may require hospitalization before the scheduled surgery. The patient’s blood glucose should not be “normal” (ie, between 80 and 120mg/dL) before surgery because this may predispose him or her to hypogly ~ e m i a . ~ Accurate physical assessment of complications related to diabetes is necessary preoperatively. It is important to identify preoperative patients with autonomic neuropathy because they can have impaired responses to hypoxia and are susceptible to the depressant effects of medications6 Autonomic neuropathy is characterized by early satiety, lack of sweating, lack of pulse rate change with inspiration or orthostatic movement, impotence, postural hypotension, resting tachycardia, and nocturnal diarrhea. Severe autonomic neuropathy can increase the diabetic patient’s risk for both painless myocardial infarction and gastroparesis with subsequent aspiration. Preoperative patients with nephropathy are more prone to fluid and electrolyte imbalances
JULY 1991, VOL 54, NO I
AORN JOURNAL
Diabetic ketoacidosis may cause classic signs of an acute abdomen, which mimic appendicitis or acute cholecystitis. in the perioperative period. Hyperkalemia and hyperphosphatemia are of particular concern. Electrolytes should be monitored closely throughout the patient's course. In spite of an early study suggesting that the time of surgery does not affect metabolic control,' it is generally recommended that diabetic patients be scheduled for surgery in the early morning because of the difficulty in maintaining metabolic balance in the fasting state.' Insulin requirements preoperatively are dependent on the intraoperative plan for insulin administration. Emergency surgery. The nurse assessing the IDDM patient in the emergency department and later in the preoperative area should ascertain the patient's usual insulin regimen and whether he or she took the routine dose before admission. The nurse in the emergency department sends a urine sample for ketones, blood samples for glucose and electrolytes, and an arterial blood gas for pH determination to the laboratory. He or Ehe also assesses the patient for signs of DKA. If the patient is in DKA, surgery should be postponed as long as possible, and treatment of DKA should be initiated." If surgery cannot be postponed, DKA can be monitored in the intraoperative period with serum glucose, potassium, phosphorous, and pH evaluations at least every hour.'" The nurse must consider that the patient in DKA may present with classic signs of an acute abdomen (eg, peritoneal inflammation, increased levels of serum amylase, fever, and leukocytosis), which may mimic appendicitis or acute cholecystitis." These signs and symptoms should resolve with appropriate treatment of the DKA. Diabetic ketoacidosis treated too aggressively may lead to congestive heart failure, increased metabolic imbalances, nausea and vomiting with potential aspiration pneumonia, hypoglycemia, 64
cerebral edema, and death. The latter two complications occur particularly in children.'*
Intraoperative Considerations
T
he goal of intraoperative therapeutic management is to avoid electrolyte imbalance and to maintain normoglycemia. Hyperglycemia has a negative effect on wound healing and increases the risk for infection. Hypoglycemia, on the other hand, increases the risk for seizures and neurological damage.I3 Although relatively uncommon, general anesthesia may induce a hyperglycemic state, whereas spinal or epidural anesthesia does Insulin administration. Two routes are available for insulin administration during surgery-subcutaneous and IV. Subcutaneous insulin is used in minor elective procedures of short duration, while continuous IV insulin is preferred for more extensive surgical procedures. A study comparing blood glucose levels in surgical patients indicated that there were no advantages to receiving subcutaneous or IV insulin preoperatively or po~toperatively.'~ Patients who received IV insulin intraoperatively, however, achieved significantly better control of blood glucose levels during the operative procedure than those who received subcutaneous insulin. If intraoperative subcutaneous insulin is planned, a portion (ie, one half to two thirds) of the morning intermediate-acting insulin should be given to the patient. If the patient takes a long-acting insulin, the usual dose may be given, but the regular insulin should held before surgery because the patient will be fasting until the procedure is completed. An IV infusion of 5% dextrose in water (D,W) is recommended when subcutaneous insulin is used. The rate of infusion is based on
JULY 1991. VOL 54, NO I
AORN JOURNAL
Table 1
Acceptable Intruoperative Blood Glucose Values Adults: 120-1 80 mg/dL Children: 120-220 mg/dL Children < five years old: 150-250 mg/dL
the patient’s daily fluid requirements. Supplemental insulin (ie, short-acting) may be administered every four hours for blood glucose values greater than 250 mg/dL If blood glucose levels continue to increase, the rate of infusion may be decreased. Hypoglycemia can be treated with a bolus of D,W, 10% dextrose in water (DloW),or 20% dextrose in water (D20W). The only acceptable insulin to administer intravenously is short-acting insulin. Intermediate- or long-acting insulins carry the risk of embolization with IV infusion. Insulin should not be added to infusions of plasma or blood because these products contain enzymes that degrade insulin.Ih When IV insulin is used, D,W or D,,W with potassium chloride also is used.” Subcutaneous insulin is not given the morning of surgery, and a fasting blood glucose level should be obtained. If the fasting blood glucose level is high, surgery should be postponed until better control is achieved. Unique insulin requirements may exist with certain patient conditions. Patients with liver disease or who are undergoing steroid therapy will have an increased need for insulin. Twice the baseline insulin may be required for patients with severe infection.lXThis is because of the relative insulin resistance that occurs during infections. Three times as much insulin may be required for patients undergoing cardiopulmonary bypass. Hypoglycemia. During surgery it is more important to avoid hypoglycemia than hyperglycemia. Table 1 lists acceptable intraoperative blood glucose levels. Hypoglycemia in the anesthetized patient is almost impossible to detect without blood glu66
cose level determinations. Generally, low blood glucose causes tachycardia, lacrimation, diaphoresis, hypertension, and a change in mood. These signs may be misinterpreted in the anesthetized patient as inadequate anesthesiaI9 or hemodynamic instability. Hourly blood glucose measurements should be taken and values less than 120 mg/dL should be treated with additional IV glucose and adjustment of the insulin infusion. Hypoglycemia may cause serious cerebral dysfunction, impaired cardiac function, pulmonary edema, bleeding from the surgical site, and death.?” Patients with renal insufficiency are especially prone to hypoglycemia because of the prolonged action of insulin. In addition, patients who receive inadequate glucose are susceptible to hypoglycemia.*’ If fluids must be restricted, a higher concentration of glucose should be used to maintain normoglycemia. Fluid requirements. In the diabetic patient, intraoperative fluids are based on individual needs. Although D,W or D,,W are the standard preferred fluids, concentrations of sodium chloride (NaC1) may be substituted when necessary. Infusions of 0.9% NaCI or 0.45% NaCl will lower the blood glucose levels falsely. Lactated Ringer’s solution should be used cautiously because the lactate converts to glucose and may promote hyperglycemia.22 Electrolyte additives may be used according to the metabolic needs of the patient. Because insulin may cause a decrease in serum potassium, this electrolyte should be monitored closely during surgery. Positioning. The circulating nurse should be extra careful when positioning the diabetic patient on the OR bed. Patients who have peripheral vascular disease or neuropathy are especially susceptible to pressure or stretch injuries.23For the patient with renal failure, the nurse should be aware of dialysis access sites and protect the sites appropriately. Children. The usual insulin dose in childhood averages 1 ukg, although pre-adolescents and adolescents may require 1.2-1.4 u/kg. Blood glucose values during surgery should be kept between 120 and 220 mg/dL Children less than
JULY 1991, VOL 54, NO 1
five years of age are especially prone to hypoglycemia because of their erratic eating and activity patterns. In addition, they have difficulty identifying symptoms of hypoglycemia. For these reasons, their usual glucose levels should be maintained between 150 and 250 mg/dL. Special care must be taken in the postoperative period to modify insulin to achieve these goals.
Postoperative Considerations
C
are of the diabetic patient following surgery involves blood glucose level monitoring every two to four hours. If the patient received subcutaneous insulin before surgery, an adequate oral caloric intake should be resumed as soon as he or she can tolerate fluids or solid food. If the patient is unable to tolerate oral intake, or is to remain NPO, an 1V infusion of glucose is continued. Subcutaneous insulin may be resumed at the next regularly scheduled time. The dose of intermediate-acting insulin should be modified according to the patient’s blood glucose level, the amount of calories consumed during the day, and exercise activity. If the patient was taking a long-acting insulin before surgery or using an insulin pump, this regimen may be resumed. In all instances, supplemental shortacting insulin may be administered every four hours to treat hyperglycemia. If an insulin infusion had been used during surgery, it should be continued until food is tolerated. The infusion rate may be adjusted according to blood glucose values obtained every two to four hours. When oral intake is tolerated, the infusion may be discontinued and subcutaneous insulin resumed. Some clinicians suggest continuing the insulin infusion through the first meal and discontinuing it just before the next meal. The patient would receive his or her usual daily dose of subcutaneous insulin one hour before discontinuing the infusion.24 The nurse must make an accurate assessment of the surgical site for infection in the postoperative period. Because patients are often discharged within a few days following surgery,
AORN JOURNAL
the nurse needs to assess that the patients have a clear understanding of the signs and symptoms of infection and encourage them to maintain blood glucose levels between 80 and 180 mg/dL. Hyperglycemia predisposes the body to infection and slows wound healing. Patients should inform their health care provider if symptoms of infection appear. Even though prophylactic antibiotics are not prescribed routinely for diabetic patients, any infection should be treated promptly.
Summary
P
hysicians and nurses need to be aware of the metabolic needs of the diabetic patient and incorporate those requirements into the plan of care during the perioperative period. With appropriate management, morbidity and mortality rates for diabetic patients who undergo surgery may approach those for the nondiabetic p o p u l a t i ~ n . ~ ~ Notes
1. M Sperling et al, “Classification and Diagnosis,” i n Physician’s Guide to insulinDependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 3- 12. 2. M Sperling et al, “Insulin treatment,” in Physician’s Guide to Insulin-Dependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association,
Inc, 1988) 31-40. 3. P G Barash, “Anesthesia and the endocrine system,” in Clinical Anesthesia, eds P G Barash, B F Cullen, R K Stoelting (Philadelphia: J P Lippincott Co, 1989) 1185-1214; C Shuman, “Surgery and diabetes,” in Diabetes Mellitus: Theory and Practice, third edition, M Ellenberg, H Rifkin, eds (Garden City, NY: Medical Examination Publishing Co, 1983) 679-687; K G Alberti, G V Gill, M J Elliott, “Insulin delivery during surgery i n the diabetic patient,” Diabetes Care 5 suppl 1 (May June 1982) 65-77. 4. K S Keith, B Pieper, “Perioperative blood glucose levels: A study to determine the effect of surgery,”AORN Journal 50 (July 1989) 103-110. 5. Shuman, “Surgery and diabetes,” 679-687. 6 . M Roizen, “Diseases of the endocrine system,” in Anesthesia and Uncommon Diseases, third edition, J Katz, J L Benumof, L B Kadis, eds (Philadelphia: W B Saunders Co, 1990) 245-292. 7. J Fletcher, M Langman, T Kellock, “Effect of 67
AORN JOURNAL
surgery on bloodsugar levels in diabetes mellitus,” Lancet 7 (July 1965) 52-54. 8. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77; M Sperling et al, “Surgery,” in Physician’s Guide to InsulinDependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 84-87. 9. M Sperling et al, “Diabetic ketoacidosis,” in Physician’s Guide to Insulin-Dependent (Type I) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 63-70. 10. Ibid, 63-70; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 6577; M I Drury, “Insulin in emergencies,” in Diabetes Mellitus, (Oxford, England: Blackwell Scientific Publications, 1986) 99-100. 11. C Saudek, “Diabetes mellitus,” in The Principles and Practice of Medicine, 21st ed, A M Harvey et al, eds (Norwalk Conn: AppletonCentury-Crofts, 1984) 889-904. 12. Sperling et al, “Diabetic ketoacidosis,” 63-70. 13. J D Benz, “Insulin use in the diabetic surgical patient,” (Pharmacist’s Corner) AORN Journal 52 (November 1990) 1057. 14. Shuman, “Surgery and diabetes,” 679-687; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 15. A Pezzarossa et al, “Perioperative management of diabetic subjects: Subcutaneous versus intravenous insulin administration during glucose-potassium infusion,’’Diabetes Care 11 (January 1988) 52-58. 16. Drury, “Insulin in emergencies,” 99-100. 17. Sperling et al, “Surgery,” 84-87; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 18. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 19. Barash, “Anesthesia and the endocrine system,” 1185-1214. 20. Shuman, “Surgery and diabetes,” 679-687; 0 C Olson, “Surgical considerations,” in Diagnosis and Management of Diabetes Mellitus, second ed (New York City: Raven Press, 1988) 157-161. 21. Barash, “Anesthesia and the endocrine system,” 1185-1214. 22. Shuman, “Surgery and diabetes,” 679-687. 23. Barash, “Anesthesia and the endocrine system,” 1185-1214; M M Bovington, M E Spies, P J Troy, “Management of the patient with diabetes mellitus during surgery or illness,” The Nursing Clinics ofNorth America 18 (December 1983) 661-671. 24. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 25. Roizen, “Diseases of the endocrine system,” 245-292.
JULY 1991, VOL 54, NO I
Black Organ Donor Recruitment The need for targeted donor recruitment efforts in minority communities was the topic of discussion at a public meeting of the Congressional Black Caucus Health Braintrust (CBCHB). According to the April 29, 1991 issue of Modern Healthcare, Louis W. Sullivan, MD, secretary of Health and Human Services, stated that he would support federal funding for communitybased educational programs to encourage more blacks to become organ donors. Positive results of an organ donor project that was launched nine years ago in Washington, DC, were reported to the participants of the CBCHB meeting. Individuals signing organ and tissue donor cards on their driver’s licenses was one of the two significant areas reported, showing an increase from 25 drivers per month in 1982 to 750 per month in 1989. The other significant area was black organ donor consent rates, which increased from 10%in 1978 to 40% in 1989. Based on these successes, there was a proposal to duplicate similar programs in 20 cities in the next five years. According to the article, Dr Sullivan called for creative solutions, but he did not specify how much, or when, funding would be made available. Genetic differences in the immune systems of blacks and whites may be the reason for the 20% failure rate in black patients who receive kidneys and bone marrow from white donors. The article cited a recent study conducted by the American Society of Transplant Physicians that indicated only 8% of kidney donors are black, while data from the federal government indicates blacks received 19.3% of all transplanted kidneys. It has been reported that blacks wait nearly twice as long as whites for kidney transplants (ie, 13.9 months versus 7.6 months). Reasons for the unequal access to transplants and a lower success rate are not known, but a disproportionate shortage of black organ donors is thought to be a contributing factor.
JULY 1991, VOL 54, NO I
AORN JOURNAL
bxamnation INSULIN-DEPENDENT DIABETES
1. Insulin-dependent patients cannot metabolize glucose for energy because a. their pancreas has been removed b. they don’t produce insulin which is required for the passage of glucose through the cell wall. c. the body compensates by breaking down fats d. insulin production is inhibited because of an overproduction of ketones 2. Which of the following statements about DKA are true? 1. When diagnosed early, it is a reversible condition. 2. Patients that are in DKA usually hypoventilate. 3. It is a medical emergency that requires intensive treatment. 4. It is caused by respiratory acidosis resulting from byproducts known as ketones. a. 1 and3 b. 2 a n d 4 c. 1 , 2 a n d 3 d. all of the above 3. Long-term complications of diabetes include which of the following? a. nephropathy b. retinopathy c. autonomic and peripheral neuropathy d. all of the above 4. When treated too aggressively, DKA can lead to a. hypoxia, tachycardia, and hypotension b. blurred vision, respiratory alkalosis, and loss of consciousness c. congestive heart failure, vomiting, hypoglycemia, increased metabolic
5.
6.
7.
8.
imbalances, cerebral edema, and death d. acquired immune deficiency syndrome Insulin-dependent patients may be hyperglycemic preoperatively because a. stress-adaptive hormones cause a rise in plasma glucose and inhibit the tissue sensitivity of insulin b. insulin always is held before surgery c. it is normal to eat chocolate when people are nervous d. general anesthesia may induce a hyperglycemic state Which of the following statements are true for administration of insulin during surgery? 1. Subcutaneous insulin is used for minor elective procedures of short duration. 2. Intraoperative IV insulin administration achieves better control of blood glucose levels during the operative procedure. 3. Short-acting insulin may be administered intraoperatively if blood glucose levels are greater than 250 mg/dL. 4. Intravenous insulin is not preferred, even for extensive surgical procedures. a. 2 only b. 1 and2 c. 1, 2, and 3 d. all of the above The only acceptable type of insulin to administer IV is a. NPH b. short-acting c. long-acting d. animal Ultralente Unique insulin requirements may exist with which of the following patients? 69
AORN JOURNAL
a. those undergoing open heart procedures b. those with liver disease or who are undergoing steroid therapy c. those with a severe infection d. all of the above 9. What solutions are preferred when 1V insulin is administered? a. D,W or D,,,W b. D,,W or D2"W c. 0.9% NaCl d. lactated Ringer's solution 10. Insulin should not be added to infusions of plasma or blood because a. there is increased chance of embolization b. these products contain enzymes that degrade insulin c. insulin breaks down vital components in both plasma and blood d. all of the above 11. Insulin may cause a decrease in what electrolyte? a. sodium b. potassium c. chloride d. phosphate 12. Hyperglycemia requires therapeutic intervention because I . it may suppress leukocyte phagocytosis and antibody responses 2. it may cause osmotic diuresis, electrolyte imbalances, and ketoacidosis 3. it may increase the amount of bleeding during surgery 4. it is almost impossible to detect in the anesthetized patient a. 1 and2 b. 2 and 3 c. 1 and3 d. all of the above 13. During surgery it is important to avoid hypoglycemia because 1. the symptoms may be mistaken for inadequate anesthesia 2. it may cause bleeding from the surgical site 3. it increases the risk for seizures and neurological damage 4. it causes impaired cardiac function and 70
JULY 1991. VOL 54, NO I
pulmonary edema a. I and 2 b. 2 a n d 3 c. 1 , 3 and4 d. all of the above 14. Diabetic patients with renal insufficiency a. are prone to hypoglycemia because of the prolonged action of insulin b. may need a higher concentration of glucose in their IV because of fluid restrictions c. are prone to hyperkalemia and hyperphosphatemia d. all of the above 15. The IDDM patient's blood glucose values should be between 120 and 220 mg/dL before surgery because 1. this is considered to be a nonketotic state 2. i t is too expensive to hospitalize patients preoperatively to obtain normal blood glucose levels 3. a normal blood glucose level would predispose the patient to hypoglycemia 4. this is the normal range for blood glucose levels a. 1 and 2 b. 2 a n d 3 c. 1 and 3 d. 1 and 4 16. Children less than five years of age are especially prone to hypoglycemia because a. toddlers do not have much sugar in their diets b. they have erratic eating and activity patterns c. they are too young to be given insulin d. it is difficult to get urine samples to test for glucose 17. It is important to assess the IDDM patient for autonomic neuropathy because of the increased risk for 1. an impaired response to hypoxia 2. susceptibility to the depressant effects of medications 3. painless myocardial infarction 4. gastroparesis with subsequent aspiration a. 1 and 2 b. 2 a n d 3
JULY 1991, VOL 54,NO 1
c. 1 and4 d. all of the above 18. Which of the following are factors the perioperative nurse should consider when the IDDM patient is admitted for emergency surgery? 1. the patient’s usual insulin regimen and whether the routine dose was taken prior to admission 2. If diabetic ketoacidosis is present, surgery should take place as soon as possible. 3. Diabetic ketoacidosis may mimic the classic signs of appendicitis or acute cholecystitis. 4. Multiple urine samples will be taken during surgery to monitor for glucose. a. 1 and 2 b. 1 and 3 c. 2 a n d 3 d. all of the above 19. The circulating nurse should be extra careful when positioning the diabetic patient on the OR bed because the patient could be 1. prone to arthritis due to the effect of hyperglycemia on the joints 2. a renal dialysis patient with an access site that must be protected 3. very obese due to large amounts of sugar in the diet 4. susceptible to pressure or stretch injuries due to peripheral vascular disease or neuropathy a. 1 and 2 b. 2 a n d 3 c. 3 and 4 d. 2 and 4 20. The nurse must make an accurate assessment of the surgical site for infection postoperatively because a. IV insulin infusions predispose the body to infection and slow wound healing. b. Hyperglycemia predisposes the body to infection and slow wound healing. c. Hypoglycemia predisposes the body to infection and slow wound healing. d. Antibiotics are not prescribed routinely.
AORN JOURNAL
Book Helps Parents Cope with Birth Defects Few publications are available to help parents of children born with birth defects cope with the shock and adjustment. A new book, Rosey . . . the impelfect angel, is the first in a series of publications about children with birth defects. The book is designed to help parents and children with birth defects cope with the trauma of being different. It is estimated that one in every 37 American babies are born with some defect, according to a news release from the publisher. Pediatric or OR nurses can use the story to help patients’ families accept the difficulties associated with birth defects or other disabilities. Rosey . . . the impelfect angel was written by Sandra Lee Peckinpah after her daughter was born with a cleft lip and palate, one of the four most common birth defects. The author said that the special care a cleft baby requires and the pain of watching her child endure so much at a very young age overwhelmed her. She finally sought help and learned to accept and handle the situation. She wanted to share her feelings with her two young sons. She recalled that the first time one of her sons saw the baby, he exclaimed, “She’s the most beautiful little girl in all the world.” That unbiased perception of beauty brought fairy tales to mind. The author said she felt called to expand the public’s perception of people with defects and disabilities. The Rosey book resulted. The story takes place in a mythic land where 12 angels tend to gardens. Rosey’s garden is difficult to keep green and flowering, and Rosey’s face looks different than the other angels. Rosey learns to understand her uniqueness and her garden grows abundantly. Her reward is to be born to a family to teach them the beauty of imperfection. The next book in the series, published by Scholars Press, will be available this spring. For more information, call (800) 348-440 1.
AORN JOURNAL
JULY 1991, VOL 54, NO 1
Answer Sheet INSULIN-DEPENDENT DIABETES
P
lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 80231 Event # 925001
Mark only one answer per question 1 2 3
Session # 5498
Program offered July 1991 The deadline for this program is Jan 31, 1992. 1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
4
5 6 7
8 9 10
AORN (ID) # If nonmember, please provide Social Security #
11 12
Name
13
Address City
14
State
Zip 15
RN license and state Florida license # (Required for F h d a CE eredil)
Phone number
16 17
Fee enclosed or bill the credit card indicated
3 MasterCard
n Visa
18 19
Card # 20
Expiration date Signature (for credit card aumonlauon)
(Turn Over) 13
JULY 1991, VOL 54, NO 1
AORN JOURNAL
Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Describe the pathophysiology of IDDM. (2) Discuss insulin therapy as it pertains to the IDDM patient. (3) Differentiate the hyperglycemic and hypoglycemic effects on the IDDM surgical patient. (4) Discuss the perioperative nursing implications for the IDDM patient undergoing surgical intervention.
(5)
2. Content, Did th~sarticle increase your knowledge of the subject matter? Was the content clear and organized? Did this article facilitate learning? Were your individual objectives met? Was the content of the article relevant to the objectives?
3. Test questions/answers. (1) Were they reflective of the content? ( 2 ) Were they easy to understand? (3) Did they address important points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s):
____
Author names and addresses:
74
AORN JOURNAL
Insulin-Dependent Diabetes ITS EFFECT ON THE SURGICAL PATIENT Juliette U. Kelly, RN; Timothy J. Kelly, MD
T
he patient with insulin-dependent diabetes mellitus (IDDM) presents a challenge to the surgical and nursing staff. In addition to providing general perioperative care, the staff must administer glucose and insulin to maintain serum glucose levels within a delicate range. With appropriate knowledge, the staff can assist the patient in maintaining metabolic stability during this challenging time.
P a thophysiology
I
nsulin-dependent diabetes mellitus is a chronic illness for which there is no known cure. Also referred to as type I diabetes, IDDM occurs annually in 15 of 100,000 people under 20 years of age. Although often considered to be a disease that primarily affects children, IDDM also occurs each year in five of 100,000 people over 20 years of age.’ The pathology of this disorder lies in the failure of the pancreatic beta cells to produce insulin. Consequently, exogenous insulin is necessary to maintain the body in a normoglycemic state. Insulin is required for the passage of glucose through the cell wall. Without adequate insulin, the body is unable to metabolize glucose for energy. The body compensates by breaking down fats, which produces byproducts known as ketones. In large amounts, ketones can cause metabolic acidosis. In diabetics, this is referred to as diabetic ketoacidosis (DKA). The symptoms of DKA are polyuria, polydipsia, hyperventilation, dehydration, fruity breath odor, abdominal pain, and altered con-
sciousness ranging from lethargy to coma. Diabetic ketoacidosis is a medical emergency that requires intensive treatment. When diagnosed early, it is a reversible condition. Long-term complications of diabetes include macrovascular disease, as well as microvascular disorders (ie, nephropathy, retinopathy, autonomic and peripheral neuropathy). Microvascular complications occur more frequently in individuals with histories of poor metabolic control. Treatment of vascular complications may include surgical intervention.
Znsulin Therapy
T
reatment for the IDDM patient includes diet, exercise, and insulin administration. The physician specifies a diet in accordance with the patient’s growth needs and
Juliette U.Kelly, RN,MS, CPNP, is the clinical nurse specialist for pediatric diabetes, James Whitcomb Riley Hospital f o r Children, Indianapolis. She received her bachelor of science degree in nursing f r o m D’Youville College in Buffalo, NY, and her master of science degree in pediatric nursing f r o m University of Michigan, Ann Arbor. Timothy J . Kelly, MD, is a resident in the Department of Otolaryngology/Head and Neck Surgery at Indiana University Medical Center, Indianapolis. He earned his medical degree at University of Michigan, Ann Arbor. 61
JULY 1991, VOL 54, NO I
AORN JOURNAL
Preoperative patients with autonomic neuropathy can have impaired responses to hypoxia and are susceptible to the depressant effects of medications.
activity level. Physical activity lowers blood glucose, therefore, exercise is advantageous in maintaining good metabolic control. The physician prescribes insulin on an individual basis. The most traditional regimen involves two injections per day. Generally, each injection is a combination of short-acting insulin with either intermediate- or long-acting insulin. Meals and snacks are required at specific times throughout the day to coincide with the peak action and duration of the insulin. It is difficult to maintain adequate control of blood glucose levels with regimens involving less than two injections per day. Flexible regimens that do not require rigid schedules for meals and snacks can be attained by using long-acting insulin with a minimal peak, such as beef Ultralente, administered once per day. At mealtime, injections of shortacting insulin can be administered based on glucose levels (sometimes referred to as a sliding-scale regimen). Another option is the insulin pump, which provides a continuous infusion of subcutaneous insulin. The time action of subcutaneous insulin varies with the species (ie, human versus animal) and type of insulin. In general, human insulin has a quicker onset, peaks earlier, and has a shorter duration than pork or beef insulins. Short-acting insulin (ie, regular or Semilente) has an onset of 30 minutes to two hours, peaks at two to four hours, and lasts six to eight hours. Intermediate insulin (ie, Lente or NPH) has an onset of two to six hours, peaks at four to 12 hours. and can last up to 24 hours. Long-acting insulin (ie, Ultralente) has a usual onset of six to 12 hours and a duration of 18 to 36 hours. Animal Ultralente takes effect very gradually with no apparent peak, while human Ultralente peaks at 10 to 14 hours. Time action of insulin also varies with the site of administration. 62
Insulin absorbs best from the least utilized sites.2
Preoperative Considerations
A
s a stressor, surgery elicits the release of a number of stress-adaptive hor.mones. Catecholamines, cortisol, growth hormone, and glucagon cause a rise in plasma glucose and inhibit the tissue sensitivity to insulin. Without therapeutic intervention, hyperglycemia may cause osmotic diuresis, electrolyte imbalances, and k e t o a c i d o ~ i s . ~ Hyperglycemia also may suppress leukocyte phagocytosis and antibody responses.” Elective surgery. When elective surgery is planned, the patient should be in good metabolic control with blood glucose values between 120 and 220 mg/dL. The patient also should be in a nonketotic state, which may require hospitalization before the scheduled surgery. The patient’s blood glucose should not be “normal” (ie, between 80 and 120mg/dL) before surgery because this may predispose him or her to hypogly ~ e m i a . ~ Accurate physical assessment of complications related to diabetes is necessary preoperatively. It is important to identify preoperative patients with autonomic neuropathy because they can have impaired responses to hypoxia and are susceptible to the depressant effects of medications6 Autonomic neuropathy is characterized by early satiety, lack of sweating, lack of pulse rate change with inspiration or orthostatic movement, impotence, postural hypotension, resting tachycardia, and nocturnal diarrhea. Severe autonomic neuropathy can increase the diabetic patient’s risk for both painless myocardial infarction and gastroparesis with subsequent aspiration. Preoperative patients with nephropathy are more prone to fluid and electrolyte imbalances
JULY 1991, VOL 54, NO I
AORN JOURNAL
Diabetic ketoacidosis may cause classic signs of an acute abdomen, which mimic appendicitis or acute cholecystitis. in the perioperative period. Hyperkalemia and hyperphosphatemia are of particular concern. Electrolytes should be monitored closely throughout the patient's course. In spite of an early study suggesting that the time of surgery does not affect metabolic control,' it is generally recommended that diabetic patients be scheduled for surgery in the early morning because of the difficulty in maintaining metabolic balance in the fasting state.' Insulin requirements preoperatively are dependent on the intraoperative plan for insulin administration. Emergency surgery. The nurse assessing the IDDM patient in the emergency department and later in the preoperative area should ascertain the patient's usual insulin regimen and whether he or she took the routine dose before admission. The nurse in the emergency department sends a urine sample for ketones, blood samples for glucose and electrolytes, and an arterial blood gas for pH determination to the laboratory. He or Ehe also assesses the patient for signs of DKA. If the patient is in DKA, surgery should be postponed as long as possible, and treatment of DKA should be initiated." If surgery cannot be postponed, DKA can be monitored in the intraoperative period with serum glucose, potassium, phosphorous, and pH evaluations at least every hour.'" The nurse must consider that the patient in DKA may present with classic signs of an acute abdomen (eg, peritoneal inflammation, increased levels of serum amylase, fever, and leukocytosis), which may mimic appendicitis or acute cholecystitis." These signs and symptoms should resolve with appropriate treatment of the DKA. Diabetic ketoacidosis treated too aggressively may lead to congestive heart failure, increased metabolic imbalances, nausea and vomiting with potential aspiration pneumonia, hypoglycemia, 64
cerebral edema, and death. The latter two complications occur particularly in children.'*
Intraoperative Considerations
T
he goal of intraoperative therapeutic management is to avoid electrolyte imbalance and to maintain normoglycemia. Hyperglycemia has a negative effect on wound healing and increases the risk for infection. Hypoglycemia, on the other hand, increases the risk for seizures and neurological damage.I3 Although relatively uncommon, general anesthesia may induce a hyperglycemic state, whereas spinal or epidural anesthesia does Insulin administration. Two routes are available for insulin administration during surgery-subcutaneous and IV. Subcutaneous insulin is used in minor elective procedures of short duration, while continuous IV insulin is preferred for more extensive surgical procedures. A study comparing blood glucose levels in surgical patients indicated that there were no advantages to receiving subcutaneous or IV insulin preoperatively or po~toperatively.'~ Patients who received IV insulin intraoperatively, however, achieved significantly better control of blood glucose levels during the operative procedure than those who received subcutaneous insulin. If intraoperative subcutaneous insulin is planned, a portion (ie, one half to two thirds) of the morning intermediate-acting insulin should be given to the patient. If the patient takes a long-acting insulin, the usual dose may be given, but the regular insulin should held before surgery because the patient will be fasting until the procedure is completed. An IV infusion of 5% dextrose in water (D,W) is recommended when subcutaneous insulin is used. The rate of infusion is based on
JULY 1991. VOL 54, NO I
AORN JOURNAL
Table 1
Acceptable Intruoperative Blood Glucose Values Adults: 120-1 80 mg/dL Children: 120-220 mg/dL Children < five years old: 150-250 mg/dL
the patient’s daily fluid requirements. Supplemental insulin (ie, short-acting) may be administered every four hours for blood glucose values greater than 250 mg/dL If blood glucose levels continue to increase, the rate of infusion may be decreased. Hypoglycemia can be treated with a bolus of D,W, 10% dextrose in water (DloW),or 20% dextrose in water (D20W). The only acceptable insulin to administer intravenously is short-acting insulin. Intermediate- or long-acting insulins carry the risk of embolization with IV infusion. Insulin should not be added to infusions of plasma or blood because these products contain enzymes that degrade insulin.Ih When IV insulin is used, D,W or D,,W with potassium chloride also is used.” Subcutaneous insulin is not given the morning of surgery, and a fasting blood glucose level should be obtained. If the fasting blood glucose level is high, surgery should be postponed until better control is achieved. Unique insulin requirements may exist with certain patient conditions. Patients with liver disease or who are undergoing steroid therapy will have an increased need for insulin. Twice the baseline insulin may be required for patients with severe infection.lXThis is because of the relative insulin resistance that occurs during infections. Three times as much insulin may be required for patients undergoing cardiopulmonary bypass. Hypoglycemia. During surgery it is more important to avoid hypoglycemia than hyperglycemia. Table 1 lists acceptable intraoperative blood glucose levels. Hypoglycemia in the anesthetized patient is almost impossible to detect without blood glu66
cose level determinations. Generally, low blood glucose causes tachycardia, lacrimation, diaphoresis, hypertension, and a change in mood. These signs may be misinterpreted in the anesthetized patient as inadequate anesthesiaI9 or hemodynamic instability. Hourly blood glucose measurements should be taken and values less than 120 mg/dL should be treated with additional IV glucose and adjustment of the insulin infusion. Hypoglycemia may cause serious cerebral dysfunction, impaired cardiac function, pulmonary edema, bleeding from the surgical site, and death.?” Patients with renal insufficiency are especially prone to hypoglycemia because of the prolonged action of insulin. In addition, patients who receive inadequate glucose are susceptible to hypoglycemia.*’ If fluids must be restricted, a higher concentration of glucose should be used to maintain normoglycemia. Fluid requirements. In the diabetic patient, intraoperative fluids are based on individual needs. Although D,W or D,,W are the standard preferred fluids, concentrations of sodium chloride (NaC1) may be substituted when necessary. Infusions of 0.9% NaCI or 0.45% NaCl will lower the blood glucose levels falsely. Lactated Ringer’s solution should be used cautiously because the lactate converts to glucose and may promote hyperglycemia.22 Electrolyte additives may be used according to the metabolic needs of the patient. Because insulin may cause a decrease in serum potassium, this electrolyte should be monitored closely during surgery. Positioning. The circulating nurse should be extra careful when positioning the diabetic patient on the OR bed. Patients who have peripheral vascular disease or neuropathy are especially susceptible to pressure or stretch injuries.23For the patient with renal failure, the nurse should be aware of dialysis access sites and protect the sites appropriately. Children. The usual insulin dose in childhood averages 1 ukg, although pre-adolescents and adolescents may require 1.2-1.4 u/kg. Blood glucose values during surgery should be kept between 120 and 220 mg/dL Children less than
JULY 1991, VOL 54, NO 1
five years of age are especially prone to hypoglycemia because of their erratic eating and activity patterns. In addition, they have difficulty identifying symptoms of hypoglycemia. For these reasons, their usual glucose levels should be maintained between 150 and 250 mg/dL. Special care must be taken in the postoperative period to modify insulin to achieve these goals.
Postoperative Considerations
C
are of the diabetic patient following surgery involves blood glucose level monitoring every two to four hours. If the patient received subcutaneous insulin before surgery, an adequate oral caloric intake should be resumed as soon as he or she can tolerate fluids or solid food. If the patient is unable to tolerate oral intake, or is to remain NPO, an 1V infusion of glucose is continued. Subcutaneous insulin may be resumed at the next regularly scheduled time. The dose of intermediate-acting insulin should be modified according to the patient’s blood glucose level, the amount of calories consumed during the day, and exercise activity. If the patient was taking a long-acting insulin before surgery or using an insulin pump, this regimen may be resumed. In all instances, supplemental shortacting insulin may be administered every four hours to treat hyperglycemia. If an insulin infusion had been used during surgery, it should be continued until food is tolerated. The infusion rate may be adjusted according to blood glucose values obtained every two to four hours. When oral intake is tolerated, the infusion may be discontinued and subcutaneous insulin resumed. Some clinicians suggest continuing the insulin infusion through the first meal and discontinuing it just before the next meal. The patient would receive his or her usual daily dose of subcutaneous insulin one hour before discontinuing the infusion.24 The nurse must make an accurate assessment of the surgical site for infection in the postoperative period. Because patients are often discharged within a few days following surgery,
AORN JOURNAL
the nurse needs to assess that the patients have a clear understanding of the signs and symptoms of infection and encourage them to maintain blood glucose levels between 80 and 180 mg/dL. Hyperglycemia predisposes the body to infection and slows wound healing. Patients should inform their health care provider if symptoms of infection appear. Even though prophylactic antibiotics are not prescribed routinely for diabetic patients, any infection should be treated promptly.
Summary
P
hysicians and nurses need to be aware of the metabolic needs of the diabetic patient and incorporate those requirements into the plan of care during the perioperative period. With appropriate management, morbidity and mortality rates for diabetic patients who undergo surgery may approach those for the nondiabetic p o p u l a t i ~ n . ~ ~ Notes
1. M Sperling et al, “Classification and Diagnosis,” i n Physician’s Guide to insulinDependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 3- 12. 2. M Sperling et al, “Insulin treatment,” in Physician’s Guide to Insulin-Dependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association,
Inc, 1988) 31-40. 3. P G Barash, “Anesthesia and the endocrine system,” in Clinical Anesthesia, eds P G Barash, B F Cullen, R K Stoelting (Philadelphia: J P Lippincott Co, 1989) 1185-1214; C Shuman, “Surgery and diabetes,” in Diabetes Mellitus: Theory and Practice, third edition, M Ellenberg, H Rifkin, eds (Garden City, NY: Medical Examination Publishing Co, 1983) 679-687; K G Alberti, G V Gill, M J Elliott, “Insulin delivery during surgery i n the diabetic patient,” Diabetes Care 5 suppl 1 (May June 1982) 65-77. 4. K S Keith, B Pieper, “Perioperative blood glucose levels: A study to determine the effect of surgery,”AORN Journal 50 (July 1989) 103-110. 5. Shuman, “Surgery and diabetes,” 679-687. 6 . M Roizen, “Diseases of the endocrine system,” in Anesthesia and Uncommon Diseases, third edition, J Katz, J L Benumof, L B Kadis, eds (Philadelphia: W B Saunders Co, 1990) 245-292. 7. J Fletcher, M Langman, T Kellock, “Effect of 67
AORN JOURNAL
surgery on bloodsugar levels in diabetes mellitus,” Lancet 7 (July 1965) 52-54. 8. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77; M Sperling et al, “Surgery,” in Physician’s Guide to InsulinDependent (Type I ) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 84-87. 9. M Sperling et al, “Diabetic ketoacidosis,” in Physician’s Guide to Insulin-Dependent (Type I) Diabetes: Diagnosis and Treatment, eds M Sperling et a1 (Alexandria, Va: American Diabetes Association, Inc, 1988) 63-70. 10. Ibid, 63-70; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 6577; M I Drury, “Insulin in emergencies,” in Diabetes Mellitus, (Oxford, England: Blackwell Scientific Publications, 1986) 99-100. 11. C Saudek, “Diabetes mellitus,” in The Principles and Practice of Medicine, 21st ed, A M Harvey et al, eds (Norwalk Conn: AppletonCentury-Crofts, 1984) 889-904. 12. Sperling et al, “Diabetic ketoacidosis,” 63-70. 13. J D Benz, “Insulin use in the diabetic surgical patient,” (Pharmacist’s Corner) AORN Journal 52 (November 1990) 1057. 14. Shuman, “Surgery and diabetes,” 679-687; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 15. A Pezzarossa et al, “Perioperative management of diabetic subjects: Subcutaneous versus intravenous insulin administration during glucose-potassium infusion,’’Diabetes Care 11 (January 1988) 52-58. 16. Drury, “Insulin in emergencies,” 99-100. 17. Sperling et al, “Surgery,” 84-87; Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 18. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 19. Barash, “Anesthesia and the endocrine system,” 1185-1214. 20. Shuman, “Surgery and diabetes,” 679-687; 0 C Olson, “Surgical considerations,” in Diagnosis and Management of Diabetes Mellitus, second ed (New York City: Raven Press, 1988) 157-161. 21. Barash, “Anesthesia and the endocrine system,” 1185-1214. 22. Shuman, “Surgery and diabetes,” 679-687. 23. Barash, “Anesthesia and the endocrine system,” 1185-1214; M M Bovington, M E Spies, P J Troy, “Management of the patient with diabetes mellitus during surgery or illness,” The Nursing Clinics ofNorth America 18 (December 1983) 661-671. 24. Alberti, Gill, Elliott, “Insulin delivery during surgery in the diabetic patient,” 65-77. 25. Roizen, “Diseases of the endocrine system,” 245-292.
JULY 1991, VOL 54, NO I
Black Organ Donor Recruitment The need for targeted donor recruitment efforts in minority communities was the topic of discussion at a public meeting of the Congressional Black Caucus Health Braintrust (CBCHB). According to the April 29, 1991 issue of Modern Healthcare, Louis W. Sullivan, MD, secretary of Health and Human Services, stated that he would support federal funding for communitybased educational programs to encourage more blacks to become organ donors. Positive results of an organ donor project that was launched nine years ago in Washington, DC, were reported to the participants of the CBCHB meeting. Individuals signing organ and tissue donor cards on their driver’s licenses was one of the two significant areas reported, showing an increase from 25 drivers per month in 1982 to 750 per month in 1989. The other significant area was black organ donor consent rates, which increased from 10%in 1978 to 40% in 1989. Based on these successes, there was a proposal to duplicate similar programs in 20 cities in the next five years. According to the article, Dr Sullivan called for creative solutions, but he did not specify how much, or when, funding would be made available. Genetic differences in the immune systems of blacks and whites may be the reason for the 20% failure rate in black patients who receive kidneys and bone marrow from white donors. The article cited a recent study conducted by the American Society of Transplant Physicians that indicated only 8% of kidney donors are black, while data from the federal government indicates blacks received 19.3% of all transplanted kidneys. It has been reported that blacks wait nearly twice as long as whites for kidney transplants (ie, 13.9 months versus 7.6 months). Reasons for the unequal access to transplants and a lower success rate are not known, but a disproportionate shortage of black organ donors is thought to be a contributing factor.
JULY 1991, VOL 54, NO I
AORN JOURNAL
bxamnation INSULIN-DEPENDENT DIABETES
1. Insulin-dependent patients cannot metabolize glucose for energy because a. their pancreas has been removed b. they don’t produce insulin which is required for the passage of glucose through the cell wall. c. the body compensates by breaking down fats d. insulin production is inhibited because of an overproduction of ketones 2. Which of the following statements about DKA are true? 1. When diagnosed early, it is a reversible condition. 2. Patients that are in DKA usually hypoventilate. 3. It is a medical emergency that requires intensive treatment. 4. It is caused by respiratory acidosis resulting from byproducts known as ketones. a. 1 and3 b. 2 a n d 4 c. 1 , 2 a n d 3 d. all of the above 3. Long-term complications of diabetes include which of the following? a. nephropathy b. retinopathy c. autonomic and peripheral neuropathy d. all of the above 4. When treated too aggressively, DKA can lead to a. hypoxia, tachycardia, and hypotension b. blurred vision, respiratory alkalosis, and loss of consciousness c. congestive heart failure, vomiting, hypoglycemia, increased metabolic
5.
6.
7.
8.
imbalances, cerebral edema, and death d. acquired immune deficiency syndrome Insulin-dependent patients may be hyperglycemic preoperatively because a. stress-adaptive hormones cause a rise in plasma glucose and inhibit the tissue sensitivity of insulin b. insulin always is held before surgery c. it is normal to eat chocolate when people are nervous d. general anesthesia may induce a hyperglycemic state Which of the following statements are true for administration of insulin during surgery? 1. Subcutaneous insulin is used for minor elective procedures of short duration. 2. Intraoperative IV insulin administration achieves better control of blood glucose levels during the operative procedure. 3. Short-acting insulin may be administered intraoperatively if blood glucose levels are greater than 250 mg/dL. 4. Intravenous insulin is not preferred, even for extensive surgical procedures. a. 2 only b. 1 and2 c. 1, 2, and 3 d. all of the above The only acceptable type of insulin to administer IV is a. NPH b. short-acting c. long-acting d. animal Ultralente Unique insulin requirements may exist with which of the following patients? 69
AORN JOURNAL
a. those undergoing open heart procedures b. those with liver disease or who are undergoing steroid therapy c. those with a severe infection d. all of the above 9. What solutions are preferred when 1V insulin is administered? a. D,W or D,,,W b. D,,W or D2"W c. 0.9% NaCl d. lactated Ringer's solution 10. Insulin should not be added to infusions of plasma or blood because a. there is increased chance of embolization b. these products contain enzymes that degrade insulin c. insulin breaks down vital components in both plasma and blood d. all of the above 11. Insulin may cause a decrease in what electrolyte? a. sodium b. potassium c. chloride d. phosphate 12. Hyperglycemia requires therapeutic intervention because I . it may suppress leukocyte phagocytosis and antibody responses 2. it may cause osmotic diuresis, electrolyte imbalances, and ketoacidosis 3. it may increase the amount of bleeding during surgery 4. it is almost impossible to detect in the anesthetized patient a. 1 and2 b. 2 and 3 c. 1 and3 d. all of the above 13. During surgery it is important to avoid hypoglycemia because 1. the symptoms may be mistaken for inadequate anesthesia 2. it may cause bleeding from the surgical site 3. it increases the risk for seizures and neurological damage 4. it causes impaired cardiac function and 70
JULY 1991. VOL 54, NO I
pulmonary edema a. I and 2 b. 2 a n d 3 c. 1 , 3 and4 d. all of the above 14. Diabetic patients with renal insufficiency a. are prone to hypoglycemia because of the prolonged action of insulin b. may need a higher concentration of glucose in their IV because of fluid restrictions c. are prone to hyperkalemia and hyperphosphatemia d. all of the above 15. The IDDM patient's blood glucose values should be between 120 and 220 mg/dL before surgery because 1. this is considered to be a nonketotic state 2. i t is too expensive to hospitalize patients preoperatively to obtain normal blood glucose levels 3. a normal blood glucose level would predispose the patient to hypoglycemia 4. this is the normal range for blood glucose levels a. 1 and 2 b. 2 a n d 3 c. 1 and 3 d. 1 and 4 16. Children less than five years of age are especially prone to hypoglycemia because a. toddlers do not have much sugar in their diets b. they have erratic eating and activity patterns c. they are too young to be given insulin d. it is difficult to get urine samples to test for glucose 17. It is important to assess the IDDM patient for autonomic neuropathy because of the increased risk for 1. an impaired response to hypoxia 2. susceptibility to the depressant effects of medications 3. painless myocardial infarction 4. gastroparesis with subsequent aspiration a. 1 and 2 b. 2 a n d 3
JULY 1991, VOL 54,NO 1
c. 1 and4 d. all of the above 18. Which of the following are factors the perioperative nurse should consider when the IDDM patient is admitted for emergency surgery? 1. the patient’s usual insulin regimen and whether the routine dose was taken prior to admission 2. If diabetic ketoacidosis is present, surgery should take place as soon as possible. 3. Diabetic ketoacidosis may mimic the classic signs of appendicitis or acute cholecystitis. 4. Multiple urine samples will be taken during surgery to monitor for glucose. a. 1 and 2 b. 1 and 3 c. 2 a n d 3 d. all of the above 19. The circulating nurse should be extra careful when positioning the diabetic patient on the OR bed because the patient could be 1. prone to arthritis due to the effect of hyperglycemia on the joints 2. a renal dialysis patient with an access site that must be protected 3. very obese due to large amounts of sugar in the diet 4. susceptible to pressure or stretch injuries due to peripheral vascular disease or neuropathy a. 1 and 2 b. 2 a n d 3 c. 3 and 4 d. 2 and 4 20. The nurse must make an accurate assessment of the surgical site for infection postoperatively because a. IV insulin infusions predispose the body to infection and slow wound healing. b. Hyperglycemia predisposes the body to infection and slow wound healing. c. Hypoglycemia predisposes the body to infection and slow wound healing. d. Antibiotics are not prescribed routinely.
AORN JOURNAL
Book Helps Parents Cope with Birth Defects Few publications are available to help parents of children born with birth defects cope with the shock and adjustment. A new book, Rosey . . . the impelfect angel, is the first in a series of publications about children with birth defects. The book is designed to help parents and children with birth defects cope with the trauma of being different. It is estimated that one in every 37 American babies are born with some defect, according to a news release from the publisher. Pediatric or OR nurses can use the story to help patients’ families accept the difficulties associated with birth defects or other disabilities. Rosey . . . the impelfect angel was written by Sandra Lee Peckinpah after her daughter was born with a cleft lip and palate, one of the four most common birth defects. The author said that the special care a cleft baby requires and the pain of watching her child endure so much at a very young age overwhelmed her. She finally sought help and learned to accept and handle the situation. She wanted to share her feelings with her two young sons. She recalled that the first time one of her sons saw the baby, he exclaimed, “She’s the most beautiful little girl in all the world.” That unbiased perception of beauty brought fairy tales to mind. The author said she felt called to expand the public’s perception of people with defects and disabilities. The Rosey book resulted. The story takes place in a mythic land where 12 angels tend to gardens. Rosey’s garden is difficult to keep green and flowering, and Rosey’s face looks different than the other angels. Rosey learns to understand her uniqueness and her garden grows abundantly. Her reward is to be born to a family to teach them the beauty of imperfection. The next book in the series, published by Scholars Press, will be available this spring. For more information, call (800) 348-440 1.
AORN JOURNAL
JULY 1991, VOL 54, NO 1
Answer Sheet INSULIN-DEPENDENT DIABETES
P
lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 80231 Event # 925001
Mark only one answer per question 1 2 3
Session # 5498
Program offered July 1991 The deadline for this program is Jan 31, 1992. 1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
4
5 6 7
8 9 10
AORN (ID) # If nonmember, please provide Social Security #
11 12
Name
13
Address City
14
State
Zip 15
RN license and state Florida license # (Required for F h d a CE eredil)
Phone number
16 17
Fee enclosed or bill the credit card indicated
3 MasterCard
n Visa
18 19
Card # 20
Expiration date Signature (for credit card aumonlauon)
(Turn Over) 13
JULY 1991, VOL 54, NO 1
AORN JOURNAL
Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Describe the pathophysiology of IDDM. (2) Discuss insulin therapy as it pertains to the IDDM patient. (3) Differentiate the hyperglycemic and hypoglycemic effects on the IDDM surgical patient. (4) Discuss the perioperative nursing implications for the IDDM patient undergoing surgical intervention.
(5)
2. Content, Did th~sarticle increase your knowledge of the subject matter? Was the content clear and organized? Did this article facilitate learning? Were your individual objectives met? Was the content of the article relevant to the objectives?
3. Test questions/answers. (1) Were they reflective of the content? ( 2 ) Were they easy to understand? (3) Did they address important points?
4. What other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s):
____
Author names and addresses:
74