Diabetic Ketoacidosis
An 18-ycar-old woman with known type 1 diabetes is in the emergency department (ED) with a diagnosis of DKA. She had run out of her basal insulin (glargine), and was only taking short-acting insulin to cover her meals. During the past 2 days she had been experiencing flu-like symptoms, feeling unwell with abdominal cramping that she attributed to stress over her college examinations. She was brought to the ED by her roommates because she was drowsy and "acting drunk." Significant findings on her admission profile were:
Treatment: In the ED, a peripheral IV was started in her right arm and 1 L of 0. 9% sodiwn chloride was infused over 1 hour. When this had infused, a new bag ofO. 9% sodiwn chloride was hung at a rate of 250 mL/h. The low serum potassium level was replaced and potassium rechecked (now 4.0 mEq/L). She was then transferred from the ED to the critical care unit for intensive management of blood glucose, insulin, and assessment of ongoing neurological and metabolic status related to DKA. At this point a second IV was started in her left arm. An IV insulin bolus was administered, and an insulin infusion started. Hourly blood glucose checks and serum potassiwn checks were started. Given her elevated white blood cell (WBC) count and elevated temperature urine cultures and blood cultures were obtained.
After 24 hours a total of 6 liters 0.9% sodium chloride was infused, blood glucose was now 298 mg/dL and was managed according to the hospital's DKA insulin protocol. Serwn potassium, scrum phosphorus, and scrwn magnesium were replaced per protocol. The anion gap had fallen to 17 indicating that the metabolic acidosis was resolving.
Six hours later the blood glucose reached 250 mg/dL and the IV solution was changed to D5.45% at 150 mL/h. Blood glucose checks continued.
The immediate plan of care is to continue the IV insulin infusion until the anion gap has ck>sed. At that time there will be a transition to a basal-bolus insulin subcutaneous insulin regime with meals.
Complete the following aentence: Intravenous isotonic 0.9% sodium chloride (normal saline) administered prior to insulin administration will ....•
(A) not impact blood glucose levels
(B) dilute blood glucose levels
(C) dangerously raise serum sodium levels
(D) decrease serwn potassium levels
Sodium bicarbonate IV is indicated in DKA in which clinical situation?
(A) High anion gap
(B) pH more than 7.0
(C) pH less than 7.0
(D) Low anion gap
In type 1 diabetes a person can appear to be "acting drunk" becau1e:
(A) Hyperventilation from Kussmaul ventilation reduces ketone bodies, lowers col and increases acetone in the bloodstream.
(B) Glucose interacts with glucagon to raise scrum alcohol levels.
(C) In DKA the gut microbiome has a fermentation effect that releases powerful peptides into the circulation that cross the blood-brain barrier making a person act inebriated.
(D) G lucosc cannot enter the brain cells without insulin.