DKA Application

CC: “I felt weak and nauseated during softball practice. I checked my blood glucose and it read HI” HPI: Mary McGee is a 21-year-old woman with a history of type 1 diabetes, diagnosed 3 years ago. She is a college senior at the local university where she also plays softball. She started using an insulin pump approximately 6 months ago. She noticed she was unusually tired and short of breath at the beginning of her practice and then began feeling weak and nauseated. She was also very thirsty during practice. Her softball coach said she seemed “a little confused.” He advised her to check her blood glucose and it read “HI”. She checked her insulin pump and noticed the pump had become disconnected. She is unsure how long she has been without insulin. She vomited two times since shortly thereafter and was transported via EMS to the ED. PMH: Type 1 DM diagnosed 3 years ago. No prior hospitalizations for DKA or prior surgeries. FH: Parents are alive and healthy. One twin sister who also has type 1 DM. SH: College student; no tobacco, alcohol, or illicit drug use. Sexually active; in a monogamous relationship. Meds: NovoLog 100 U/mL, per insulin pump Basal rates: • 0.6 U/hr 0000–0300 • 0.9 U/hr 0300–0700 • 0.8 U/hr 0700–1100 • 0.7 U/hr 1100–1730 • 0.8 U/hr 1730–0000 Correction factor: 1 U:40 mg/dL >120 mg/dL Insulin:carbohydrate ratios: • 1:10 insulin:carbohydrate before breakfast • 1:15 insulin:carbohydrate before lunch and dinner Glucagon injection kit, as needed Ortho-Cyclen (35 mcg ethinyl estradiol/0.25 mg norgestimate) one tablet PO once daily × 3 years Allergies: NKDA ROS: Complains of blurry vision, lethargy, shortness of breath, nausea, polyuria, and polydipsia. Denies constipation, diarrhea, and headache. Physical Examination Gen: WDWN Caucasian woman appearing her stated age, with deep respirations, ketones on her breath, and slurred speech; slightly confused, but responds appropriately to questions VS: BP 101/72 mm Hg, P 123 bpm, RR 32, T 37.0°C; Wt 56 kg, Ht 5′6″; BMI 19.9 kg/m2 Skin: Unremarkable HEENT: PERRLA, EOMI; mucous membranes are dry Neck/Lymph Nodes: Supple without lymphadenopathy or thyromegaly Lungs: CTA, Kussmaul respirations CV: S1 and S2 are normal without S3, S4, murmur or rub; RRR Abd: NT/ND Genit/Rect: Deferred MS/Ext: No edema, pulses 2+ throughout, mild calluses Neuro: A&O × 3; DTRs 2+ throughout; feet with normal sensation and vibration Labs Na 136 mEq/L WBC 15.0 × 103/mm3 K 4.8 mEq/L RBC 4.61 × 106/mm3 Cl 101 mEq/L Hgb 14.2 g/dL CO2 10 mEq/L Hct 40.7% BUN 23 mg/dL Platelets 239 × 103/mm3 SCr 1.4 mg/dL Ketones positive Glu 479 mg/dL hCG negative ABG: pH 7.26; PaCO2 21 mm Hg; PaO2 128 mm Hg; HCO3 7.1 mEq/L; O2 sat 97% UA: (+) Ketones; (+) glucose Chest X-Ray: Normal ECG: Sinus tachycardia The hospital attending physician knows you are new and hands you this (see next page). “This is the algorithm we use at this hospital, let me know your recommendations when we round in 30 minutes”. The other APPE student reminds you the corrected sodium = measured sodium + [1.6 (glucose – 100) / 100] and the anion gap = [Na] – [Cl] – [HCO3]. 1. Highlight (in the case above) the clinical presentation of DKA. See above. 2. What is this patient’s corrected sodium? **Formula given on exam** Corrected sodium = measured sodium + [1.6 (glucose – 100) / 100] Corrected sodium = 136 + [1.6(479-100)/100] Corrected sodium = 142.064 mEq/L 3. What is this patient’s anion gap? **EXAM: NEED TO MEMORIZE FORMULA** Anion gap = [Na] - [Cl] - [HCO3] Anion gap = 136 - 101 – 7.1 Anion gap = 27.9 > 12 4. What is your care plan based on the DKA treatment algorithm above? Be sure to provide rationale for your treatment plan. IV fluid: ½ Normal Saline (0.45% NS). Check labs every 2-4 hours. Insulin (IV route): - Initial bolus followed by a continuous infusion - Bolus: Regular insulin at a dose of 0.1 units/kg o 0.1 unit/kg * 56kg = 5.6 units IV regular insulin Continuous infusion of regular insulin at a rate of 0.1 units/kg/hour o 0.1 units/kg/hr * 56kg = 5.6 units IV insulin per hour Rationale --> Patient needs insulin because in DKA, there is a severe deficiency of insulin, which leads to hyperglycemia and ketosis. Blood glucose is 479 mg/dL, per ADA guideline, initiate insulin if BG > 140 K: Pt K is 4.8 (between 3.3 and 5.3). Give 20-30 mEq/L IV fluid to maintain potassium between 4-5 mEq/L Bicarb: No bicarb needed. Bicarbonate administration is not recommended as routine treatment for DKA. - The body's compensatory mechanisms, such as increased ventilation (Kussmaul respirations), help correct acidosis. EXAM: Insulin infusion rate calculation – need to know 0.1 units/kg/hr IV to PO levothyroxine calculation