ENDOCRINOLOGY Flashcards
A 31-year-old diabetic male presents to the emergency department because of abdominal pain. The patient states that he has not been feeling well for the past two days, and has been vomiting intractably. He stopped taking his regular dose of insulin because he was unable to “hold anything down” and was not eating well.
The patient stopped vomiting. His blood glucose dropped to 54 mg/dl. The insulin infusion was stopped, and D5% + NS with KCl was continued.
A third basic metabolic panel shows: Sodium: 130 mEq/dL Potassium: 3.8 mEq/dL Carbon dioxide: 14 mmol/L Chloride: 98 mmol/L BUN: 22 mg/dL Creatinine: 1.4 mg/dL Blood glucose: 324 mg/dL
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Most patients with DKA have 5-8 liters of fluid deficit
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CBC: Hematocrit: 37% WBC: 11,000/cmm, normal differential Platelets: 240,000/cmm Serum chemistry: Sodium: 129 mEq/dL Potassium: 3.4 mEq/dL Carbon dioxide: 8 mmol/L Chloride: 90 mmol/L BUN: 48 mg/dL Creatinine: 2.3 mg/dL Blood glucose: 560 mg/dL Ketones were positive in the urine and serum.
the patient should start receiving potassium supplementation at the outset of the treatment
intravenous normal saline with potassium and insulin infusion (7 units/hr.).
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Seven hours after his admission to the intensive care unit, the patient’s blood glucose is 210 mg/dl, and his clinical status has improved.
Decrease the insulin infusion rate, and change the fluid to D5 ? NS with potassium.A delay in starting dextrose infusion usually results in the prolongation of ketone clearance from the serum
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Continue normal saline, and start administering insulin by subcutaneous route after an hour overlap.
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Switching to oral feeding and subcutaneous insulin should be done at an appropriate time anion gap has normalized, bicarbonate is over 10 mEq/l, the patients are able to tolerate food,
Another common mistake in the management of DKA is stopping intravenous infusion of insulin without an overlapping dose of subcutaneous insulin.
Generally, rapid acting insulin is started when the switch from infusion to subcutaneous insulin is made. Because subcutaneously administered
insulin takes time to be absorbed, it should be administered 30 to 60 minutes before insulin infusion is stopped. Failure to do so could result in rapid recurrence of DKA.
