Critical Care Medicine-Endocrine Disorders>>>>>Diabetes Mellitus
Question 5#

A 27-year-old man with a history of obesity and substance abuse is found obtunded. His laboratory findings are:

Chemistry:

• Sodium 135 mmol/L
• Potassium 3.0 mmol/L
• Chloride 105 mmol/L
• CO₂ 10 mmol/L
• Blood Urea Nitrogen 42 mg/dL
• Creatinine 2.1 mg/dL
• Glucose 570 mg/dL

Arterial Blood Gas:

• pH 7.21
• PaCO₂ 24
• PaO₂ 95
• Serum ketones positive

Initial treatment for him should include all of the following EXCEPT:

A. Normal saline at 500 to 1,000 mL/h during the first 1 to 2 hours
B. Replete potassium by administering potassium chloride
C. Intravenous insulin infusion to correct serum glucose
D. Identify and treat precipitating event

Correct Answer is B

Comment:

Correct Answer: B

Diagnostic criteria for DKA consist of the triad of hyperglycemia (serum glucose >250 mg/dL), acidemia (pH <7.3), and ketonemia. The osmotic diuresis associated with glycosuria results in total body water, sodium, potassium, and phosphate deficits. Initial treatment consists of administration of normal saline to restore intravascular volume and renal perfusion. If the serum potassium is less that 3.3 mmol/L, potassium should be repleted before starting insulin as correction of volume depletion and acidosis, and insulin can all worsen hypokalemia. Once the serum sodium is greater than 3.3 mmol/L, insulin should be started. The recommended dose for regular intravenous insulin is a bolus of 0.1 U/kg followed by a continuous infusion at 0.1 U/kg/h. In patients with mild to moderate DKA, subcutaneous rapid-acting insulin analogues can also be considered. 

A search for a precipitating event should be initiated. The most common associated events are infection and inadequate insulin therapy. Other precipitating factors include medications that affect carbohydrate metabolism (glucocorticoids, thiazide diuretics, sympathomimetic agents), SGLT2 inhibitors, cocaine use, and malfunction of continuous subcutaneous infusion devices.

References:

1. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patient with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(12):2739-2748.
2. Umpierrez G, Korykowski M. Diabetic emergencies – ketoacidosis, hyperglycemic hyperosmolar state, and hypoglycemia. Nat Rev Endocrinol. 2016;12:222-232.