Heartbreak to Happiness: Striving to Improve Outcomes for the Patient in DKA

Gelato, Jill

Background: Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that warrants prompt recognition and a multidisciplinary approach to provide intensive management and monitoring of both mother and fetus. DKA is estimated to occur in 1 to 2% of pregnancies complicated by preexisting diabetes (Parker) with 10 to 30% of women having a serum glucose less than 250 mg/dl upon diagnosis. DKA poses a significant risk for the fetus, with perinatal mortality rates reported between 9% and 35% (Whiteman). Factors that increase the risk of DKA in pregnant patients include stress, trauma, infection, poor patient compliance, insulin pump failure, accidental omission of insulin, and medications utilized in the obstetric setting. It is crucial that nurses are familiar with the clinical signs of DKA so that prompt and appropriate treatment can be initiated to optimize outcomes for both the pregnant woman and her fetus. To better understand the signs and symptoms of DKA, an outline of the multisystem effects of a patient in DKA will be provided.

Case: The presentation will include a case study of a patient who won our hearts with her story, one who reminded us why our passion remains in maternal child nursing. While our case study recently delivered a healthy 38 week male infant, her previous pregnancy and delivery resulted in an intrauterine fetal demise (IUFD) following an episode of DKA. Not only will a timeline be presented outlining the course of both pregnancies, but her personal journey from grief to acceptance will be shared.

Conclusion: A problem solving method aimed to identify the root cause of an event, known as a Root Cause Analysis, was conducted utilizing a multidisciplinary team to review and discuss the case. Opportunities were presented to improve patient care and patient outcomes of the diabetic patient admitted with a diagnosis of uncontrolled blood sugars in recognition of DKA. At the conclusion, the team decided to develop a Diabetic Ketoacidosis MD order set and to provide education in the form of Web Education as well as in the formal classroom setting for resident and nursing staff.

Keywords: pregnancy, Diabetic ketoacidosis, intrauterine fetal demise