Critical Care Medicine-Endocrine Disorders>>>>>Management During Critical Illness
Question 7#

A 22-year-old man with type 1 diabetes since age 11 presents with fever, drowsiness, and abdominal pain. These symptoms started 2 days ago, and he has been unable to tolerate food or water. Vital signs are T 38.2 HR 122 and BP 105/70 mm Hg. Laboratory tests are notable for:

• glucose 480 mg/dL
• Sodium 154 mEq/L
• Potassium 5.5 mEq/L
• Chloride 114 mEq/L

An ABG shows:

• pH 7.2
• PaCO₂ 28 mm Hg
• PaO₂ 95 mm Hg
• HCO₃ 9 mEq/L

erum and urine ketones are positive. He undergoes fluid resuscitation with normal saline and receives an IV insulin bolus followed by a continuous insulin infusion. After 3 hours of treatment, his blood glucose is 250 mg/dL.

What is the most appropriate IV fluid management at this time?

A. Continue normal saline infusion and add glucose and potassium
B. Continue normal saline infusion and add glucose
C. Start half-normal saline with glucose and potassium
D. Start half-normal saline with glucose

Correct Answer is C

Comment:

Correct Answer: C

This patient presents in diabetic ketoacidosis. The immediate treatment is fluid resuscitation with normal saline to restore intravascular volume and an insulin IV bolus of 0.1 to 0.2 U/kg, followed by a continuous IV infusion at 0.10 U/kg/h. Serum glucose should be assessed hourly with the goal of lowering it by 50 mg/dL/h. The insulin infusion should be titrated downward as glucose levels are reduced. Serum electrolytes should be assessed every 2 to 4 hours. When the serum glucose is in the 200 range, glucose is added to the intravenous fluids. Starting glucose avoids hypoglycemia, while allowing continued administration of IV insulin to reverse ketogenesis. Once intravascular volume is restored, intravenous fluids should be changed to hypotonic saline to treat the ongoing freewater deficit and avoid hyperchloremic acidosis that can result from administration of large volumes of normal saline. Despite initial presence of hyperkalemia, with the administration of insulin and correction of acidosis hypokalemia will develop and should be treated with IV potassium. 

References:

1. Boord JB, Graber AL, Chistman JW, Powers AC. Practical management of diabetes in critically ill patients. Am J Respir Crit Care Med. 2001;164:1763-1767.
2. Kohler K, Levy N. Management of diabetic ketoacidosis: a summary of the 2013 joint british diabetes societies guidelines. 2014;15(3).
3. Vincent JL, Abraham E, Moore FA, et al, eds. Textbook of Critical Care. 7th ed. Philadelphia, PA: Elsevier; 2017.