Alterations in Pancreatic Function: Hyperglycemia (Nursing)

00:00 So we've talked about hypoglycemia. In this presentation, we're going to talk about hyperglycemia. We'll talk a little bit about the definition and some physiology, a few of the causes, how your patient might present, and the management you can expect. So, what is hyperglycemia? Turns out the definition isn't quite that easy.

00:26 It's when the glucose is too high, but when is the glucose too high? This is often defined as blood glucose greater than 125 mg/dL. That's kind of in the general population. It turns out in the hospital it's not that easy to define. So, although the level is greater than 125 mg/dL are often observed in patients in the hospital, we don't really feel the need to treat it until it starts causing symptoms. So, these levels are pretty common in neonates especially if they're receiving a glucose containing infusion and so they might not need any intervention at that point. High glucose really becomes a problem when it creates symptoms. So, if it is causing diuresis because the glucose is too high, that is when we know we have a problem and so often we're going to be able to treat it at that point. So, this often doesn't happen until your glucose levels are greater than 200 mg/dL. So what causes hyperglycemia? In neonates, it turns out that neonates have a hard time adapting to glucose infusions. And why might that be? So, one of the reasons is that sometimes they can't decrease their own glucose production. Remember, your liver makes a little bit of glucose and that makes it available for your body and sometimes when you're getting additional glucose through IV fluids, the neonates they just haven't been able to adapt to that yet. They also sometimes can't increase the use of the glucose that they're receiving. Often in older children and adults when we start receiving more glucose, our body adapts a little bit and we just start using it at a faster rate. Neonates don't really have that adaptability. The inability to do these 2 things is often related to a clinical condition. So what might those be? Some of the clinical conditions that can cause these issues include sepsis. Maybe they were born premature. There might be other forms of stress. You can think surgery or perhaps they're needing mechanical ventilation that can really stress the body out.

02:48 Certain drugs can cause this problem. So, phenytoin if the infant has seizures; dopamine, epinephrine, and steroids are definitely a cause of hyperglycemia. In addition, some infants develop neonatal diabetes mellitus. This is pretty rare and it actually resolves spontaneously in about 20% of cases. So, hyperglycemia is more common in preterm infants than in full-term infants because of some of these contributory factors. They just have a more poor insulin response. They also have that incomplete suppression of the glucose production like we talked about in the previous slide. That suppression of this hepatic glucose production in response to glucose infusion also varies in very immature infants and it's just an incomplete process and that's why neonates have a harder time with this. Increased secretion of counter regulatory hormones associated with stress, so think your epinephrine and your cortisol. Neonates just aren't as good at tolerating these and they can cause hyperglycemia as well. So causes of hyperglycemia in infants and children are a little bit different. So, you might have type 1 or type 2 diabetes that is developing.

04:11 This is the most frequent cause for hyperglycemia in infants and children. There might be other endocrine conditions. So, they might have Cushing's syndrome, perhaps a pancreatic disease that isn't related to the type 1 or type 2 diabetes so think pancreatitis. Again, there are certain medications. If you have a hospitalized child that has been put on steroids and some of the antiepileptic drugs, for example phenytoin, those can cause hyperglycemia, and significant stress like surgery or trauma can also cause hyperglycemia. So what's this going to look like in your patient? So, infants might have a pretty non-specific presentation. I know you're probably seeing a pattern in some of these presentations that infants is often difficult to determine what their presentation is going to look like. So, they might not have any symptoms at all or they might just be a little bit more irritable than normal. They might have a higher urine output and they also might show you signs of dehydration. So if an infant is crying and you don't notice any tears or you go to feel that soft spot on their head, the fontanelle, and you notice it's a little bit depressed or sunken or they have poor skin turgor, any of those signs of dehydration could indicate that they're having some hyperglycemia because that causes losses through the urine. Now, children will often exhibit more classic signs of hyperglycemia and what are those? So, those classic 3 P's that we have discussed in some of our previous presentations, those are polyuria, polyphagia, and polydipsia. So when you have polyuria, that urine output is just really highly increased. There is a large amount of urine output. Polyphagia is when the child is really feeling the need to eat more frequently and at a higher amount because they can't use the glucose in their body, their body is telling them they need energy so they continue to eat. Polydipsia is because they're losing water through the urine because of that polyuria and because they're losing water through the urine, they're getting dehydrated and their body is telling them they need to rehydrate. So they become thirsty and they drink much more than they would normally drink. In addition to this, you may have symptoms that are even similar to DKA and there is another lecture that goes over all of the signs and symptoms of DKA, but briefly you might notice differences in your neurological symptoms, changes in your breathing, fast and deep breathing, and you might notice fruity smelling breath.

07:01 Additionally, children might exhibit even weight loss and anorexia if the hyperglycemia has going on for a prolonged period of time. Initially, remember, patients are going to want to eat a lot but hyperglycemia over a prolonged period of time causes a lot of stomach upset and when that happens children generally stop eating. They might have nocturia and enuresis, so the patient has greatly elevated urine output and they're getting up all night long because they have to go to the bathroom. They also might have some bedwetting and it's a really big red flag if a child who has never wet the bed before all of the sudden just starts wetting the bed.

07:43 They might experience nausea and vomiting and abdominal pain. Those can be typical symptoms for hyperglycemia. Now, we'll take the opportunity to talk about some management for hyperglycemia. Management of neonatal hyperglycemia is really related to that glucose infusion rate. So, you're going to want to reduce that glucose infusion rate to bring that hyperglycemia down. This is usually accomplished by reducing the amount of dextrose in IV fluids. Now, I do want you to understand this is a short-term solution because it reduces the calories that the infant is receiving and reducing the calories can impair growth. So, overall you're going to want to fix the underlying problem and/or you want the infant to become able to tolerate oral feeding either breastmilk or formula and glucose tolerance typically improves when infants start feeding by mouth. So, in addition to that management for hyperglycemia for other patients, is going to include often insulin therapy. So, if you have a blood glucose level of 200 to 250 and your patient has started exhibiting symptoms, then we'll start an insulin infusion. This also allows you to give a higher GIR if your patient is still on IV fluids and your patient is able to receive more calories which can be very beneficial. I do want you to remember that any time you start an insulin drip, you have the risk of hypoglycemia. So, you have to remember to check that blood glucose and you check it pretty frequently when you're on a continuous infusion. Remember that hypoglycemia can cause seizures, coma, and death. We would really like to avoid that. So, additionally as you're managing the hyperglycemia, I mentioned you're going to be checking that blood glucose. So when you're trying to figure out exactly how much dextrose or glucose your patient is going to need, you're going to frequently check that blood glucose. So, you might even be checking it every hour initially. Once, you've determined how much dextrose your patient needs and that blood glucoses remain stable for a period of time and you're not seeing symptoms, then you can move to checking that glucose maybe even just daily. So you're also going to want to treat any underlying cause that might be contributing to the hyperglycemia. So for example if your patient has sepsis, you're going to want to administer antibiotics and do any other treatments that are necessary to treat the underlying cause of the hyperglycemia. So, one of the most important things that I want you to remember is that hyperglycemia is somewhat difficult to define. It's hard to give an exact number that's considered hyperglycemia. The most important thing for you to remember is that you're going to start treatment when your patient starts exhibiting symptoms.