Brian is a 54 year old, African American male, 73 kg, admitted to the MICU with
ID: 848542 • Letter: B
Question
Brian is a 54 year old, African American male, 73 kg, admitted to the MICU with diabetic ketoacidosis, and a request to monitor respiratory status. He has Type 1 Diabetes Mellitus of 35 years duration. After admission to the ICU, he had multiple episodes of emesis. Brian said he had been vomiting for the past 2 days and admitted to skipping several doses of insulin recently. He reported that he had been feeling feverish at home and was exhibiting occasional coughing episodes.
Brians assessment:
Labs:
Hgb 14.5 gm/dl
Hct 58%
Na 126 mmol/L Creatinine 4.9 mg/dl
K 5.3 mmol/L BUN 52 mg/dl
Cl 95 mmol/L Glucose 560 mg/dl
Phos 6.8 mmol/L A1c 7.8 %
Ca 8.8 mmol/L
ABGs on 50% FM Urine
PH 7.19 Spec grav 1.015
PaO2 100 mm Hg Ketones 4+
PaCO2 20 mm Hg Leukocytes Few
HCO3 7.5 mmol/L Glucose 4+
SaO2 98% on 2 L RBCs many
Home insulin and medications:
Glargine 26 units SQ daily and Aspart 8 units SQ with meals
Lipitor
Reglan
Beta Blocker
ASA
1. Discuss the physiology of DKA.
2. List the classic signs and symptoms of DKA.
3. What type of acid base imbalance does this person have?
4. What type of electrolyte imbalance does this person have?
5. Discuss the lab values:
Chemistry
ABGs
Urinalysis
6.. Calculate the anion gap. Why is it important to follow the anion gap in DKA?
.. What are the potential precipitating factors for DKA in general and for Brian specifically?
6. Utilizing the DKA protocol, how do you initiate insulin management for Brian?
Insulin bolus 0.15 units X 73 kg=10.9 units; 10 unit bolus
Hour of Infusion
Blood Glucose
Insulin Infusion Rate
Glucose Change
1
560
2
515
(Change to algorithm 2)
6 units
45
3
460
12 units
55
4
385
16 units
75
5
315
12 units
70
6
245
Change ivf to D51/2
8 units
70
7
175
4 units
70
8
125
3 units
50
9
60
Off x 1 hour
65
10
68
Off x 1 hour
8
11
100
(Change to algorithm 2)
0.5 units
32
7. Discuss other treatments that would be initiated.
8. List the potential complications associated w
Hour of Infusion
Blood Glucose
Insulin Infusion Rate
Glucose Change
1
560
2
515
(Change to algorithm 2)
6 units
45
3
460
12 units
55
4
385
16 units
75
5
315
12 units
70
6
245
Change ivf to D51/2
8 units
70
7
175
4 units
70
8
125
3 units
50
9
60
Off x 1 hour
65
10
68
Off x 1 hour
8
11
100
(Change to algorithm 2)
0.5 units
32
Explanation / Answer
Physical examination
On physical examination, Chelsea was very lethargic but in good body condition (body condition score [BCS] of 3/5). She was panting, her mucous membranes were icteric and tacky (estimate approximately 5% dehydrated) and the CRT was <2 seconds. She was mildly tachycardic and her pulses were strong and synchronous. She was pyrexic with a temperature of 104
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