Modern medical science based case discussion for doctors & hospitals.
A 48 Yr patient comes with abdominal pain, nausea and vomiting, K/C/o Diabetes mellitus
Dry mucous membranes, confused
Urinary Ketones +ve
(If RBS >= 200, do dipstick test to rule out the hyperglycemia or Diabetic Ketoacidosis)
Low Bicarb < 18
Low pH < 7.3
High Anion Gap Acidosis
Increased BHB (Beta-hydroxybutyrate), Serum Ketones
Non-compliance with insulin
Type 1 > Type 2
Stress – Sugary Hormones (cortisol, Glucagon, Growth Hormone, Catecholamines)
Sugar is high
Body thinks that we are starving
Starts making ketones for energy
Sugar causes osmotic diuresis
Intracellular dehydration – 6 lit deficit
What will you do?
Admit in ICU. Monitor, RBS & SpO2
Don't ever give Insulin in this case!!!
First, We will give IV Fluids – BSS/NS
Send for ABG, Blood Chemistry, ECG, CBC
And… Wait for Potassium
NO INSULIN till Potassium is verified on paper from tests
Once you know that K is > 3.5 then only start insulin 0.1 U/kg
70 kg man = 7 Units/hr
20 ml/kg isotonic Crystalloid
ECG – Potassium
Search for the Cause
Did he skip insulin?
Target of Insulin Infusion
Is not correction of Hyperglycemia
It is correction of Acidosis HCO3 > 15, pH > 7.3 & Anion Gap < 12
If RBS < 250, add Dextrose to Fluids
Treatment of Acidosis?
Yes, you can give Sodabicarb
Only if patient is in cardiac arrest, severe Hyperkalemia, or severe hypotension
What about Intubation?
Please don't Intubate, RR 30
Senior most expert can decide and Intubate within few seconds in case it is unavoidable
Check Mental status hourly
If altered Sensorium, consider cerebral edema
Stop IV, Elevate Head end
Osmotic Diuresis (Mannitol)
Start with Fluid NS
First Correct Potassium
Insulin till Acidosis Resolves
Watch for Cerebral Edema