DKA- how often do you see the same ones

[HyperRNRachel]

We have one girl who comes in every 2 months in DKA. NO viens anymore, so now we are restricted to central lines! I honsestly think she does not given herself insulin in order to maintain a VERY low weight- she looks anorexic. And, although, she comes in with n/v (i have never seen her vomit) she always has a negative ct and ultrasound but asks for pain meds! How often do you see the same DKA patients? Does anyone know the name of the condition for DM patients who do not administer insulin in order to control weight?

Rachel

[Guitar_Heroine]

I've heard it called diabulimia but I'm not sure if that's an official term

[MisterSimba, BSN]

that is so sad! i hope she gets the help she needs!

i got this from medicinenet.com:

while insulin keeps their muscle mass from breaking down, it also encourages fat storage. as a result, patients learn to manipulate their insulin - often skipping doses in an attempt to reduce weight gain. the term for this condition is "diabulimia." patients can become quite savvy with this technique, taking just enough insulin to avoid going into diabetic ketoacidosis, and narrowly avoiding hospitalization.

while diabulimia is a term that has only cropped up in recent years and is not a recognized medical condition, the american diabetes association has long known about insulin omission as a tactic to lose weight. diabulimia can occur in any patient with type 1 diabetes, but unfortunately it is seen more often in young girls and women with the disease, similar to other body image disorders.

the repercussions of manipulating insulin in such a manner can be enormous. patients who do this have higher blood sugar levels than are healthy, and as a result, become dehydrated, fatigued, and experience a breakdown in muscle tissue. in the long term, this condition is associated with an accelerated development of diabetic complications such as eye disease, kidney disease, and limb amputations due to vascular disease.

while this disorder is relatively well known to endocrinologists that treat a large number of patients with type 1 diabetes, it is not often recognized by primary care providers or by family members.

[dansingrn]

Unfortunately, there are many reasons kids with type 1 diabetes skip their insulin, and its not always to be thin. Depression is a huge issue with chronic disease-and when people are depressed they can sometimes ignore all kinds of self-care. With depression and diabetes together, the chronic high blood sugars and lack of self-care behaviors combine to create a downward spiral that repeats over and over with bouts of DKA.

Serious family issues and lack of problem-solving and coping skills also contribute to repeated DKA.

Rachel - to answer your question about how often we see repeats - We see a handful of frequent fliers who seem to come in over and over. We see them very frequently as outpatients to establish trusting relationships and work together on goals. We have to be happy with baby steps in improvement, but we often see amazing turn arounds! Our high risk diabetes team has a PNP, MD, social worker and psychologist.

I hope your patient gets the long-term support she needs to get better, there is no quick fix!

[quirkieone]

if your facility has emergency dept. case managers that follow up with frequent flyers they should be notified. they are supposed to help patients use the er appropriately, something like more than 3 visits a year for the same reason should be investigated but it depends on the facility.

[rph3664]

There are several names that are very familiar to us. One of them averages - get this - a DKA admission ONCE A MONTH. I once saw a note on an order sheet from this person's endocrinologist regarding a referral to a psychiatrist or psychologist (not sure which) in our region who specializes in treating noncompliant type I diabetics with psychiatric issues.

I have no idea if this person went, or if so, what happened.

ETA: Lots of adult-onset diabetics do not take their meds properly either, because they gain weight on them.

[PeachyERNurse, BSN, RN]

that is so sad! i hope she gets the help she needs!

i got this from medicinenet.com:

while insulin keeps their muscle mass from breaking down, it also encourages fat storage. as a result, patients learn to manipulate their insulin - often skipping doses in an attempt to reduce weight gain. the term for this condition is "diabulimia." patients can become quite savvy with this technique, taking just enough insulin to avoid going into diabetic ketoacidosis, and narrowly avoiding hospitalization.

while diabulimia is a term that has only cropped up in recent years and is not a recognized medical condition, the american diabetes association has long known about insulin omission as a tactic to lose weight. diabulimia can occur in any patient with type 1 diabetes, but unfortunately it is seen more often in young girls and women with the disease, similar to other body image disorders.

the repercussions of manipulating insulin in such a manner can be enormous. patients who do this have higher blood sugar levels than are healthy, and as a result, become dehydrated, fatigued, and experience a breakdown in muscle tissue. in the long term, this condition is associated with an accelerated development of diabetic complications such as eye disease, kidney disease, and limb amputations due to vascular disease.

while this disorder is relatively well known to endocrinologists that treat a large number of patients with type 1 diabetes, it is not often recognized by primary care providers or by family members.

wow. never heard this term before. i learn something new everyday.

[nursejennie76]

We have 3 at least monthly DKA'ers that come to my ER-- it is very frustrating, becasue the problem is preventable!!!! I usually give them the lecture about there limbs being cut off ther body and being on dialysis, it does no good they always come back!! But I feel better for speaking my mind in the meantime!!

[dansingrn]

With DKA frequent flyers the issue is never about basic DM education or lack of knowledge about the possibilities of dialysis, amputations, or other complications. I know we get consults from the PICU all the time for "diabetes education" on these kids. They can quote you chapter and verse what they are supposed to do - they are noncompliant for many reasons other than knowledge deficit.

Its not as simple as "why in the world would they skip their insulin?" Think about all the known risks associated with obesity and smoking, yet people continue to smoke, not exercise and eat poorly. The same thing in a way.

[LilgirlRN, ADN, RN]

We see the same ones over and over again. A long time ago we had the same guy that came in all the time. Mid thirties but had been diabetic most of his life. He was qalso an IV drug abuser. The last tmie he came in, his glucose was over a thousand, he couldn't even move to scratch his own nose. I was surprised he was awake actually. He died the next day in ICU.

[dansingrn]

Have a frequent flier in now, glucose at admission 1226, bicarb undetectable. Discharge from last DKA admission? Five days ago!!!! And patient and his mom both swear he hasn't missed any insulin doses! Their friend suggested maybe he has a virus that is "eating up his insulin!" His glucoses 5 days ago at discharge ranged 100-120 all day.

[rph3664]

Have a frequent flier in now, glucose at admission 1226, bicarb undetectable. Discharge from last DKA admission? Five days ago!!!! And patient and his mom both swear he hasn't missed any insulin doses! Their friend suggested maybe he has a virus that is "eating up his insulin!" His glucoses 5 days ago at discharge ranged 100-120 all day.

Our DKA FFs usually have pumps, and they say they haven't missed a dose but their pumps say otherwise.

What did this guy do, go home and eat nothing but candy? Oh, yeah.