December 15, 2024

24-year-old woman with type 1 diabetes mellitus and poor compliance is admitted to the ICU

By Med-Challenger · 2 minute read

A 24-year-old woman with type 1 diabetes mellitus and poor compliance is admitted to the intensive care unit where she is diagnosed with diabetic ketoacidosis.

Initial laboratory findings include positive serum ketones, a blood glucose level of 525 mg/dL, arterial pH of 7.09, a potassium level of 4.5 mg/dL, and a sodium level of 128 mg/dL.

She is anxious and complains of nausea and abdominal pain. She is not confused.

What is the first therapeutic intervention after admission to the intensive care unit?

subcutaneous insulin detemir 25 units
restore circulating volume with boluses of normal saline
sliding scale insulin
intravenous bolus of regular insulin 0.15 units/kg

The correct answer is:

restore circulating volume with boluses of normal saline

In a patient with diabetic ketoacidosis, the initial therapeutic intervention should be the restoration of circulating volume using normal saline. After determining the level of dehydration, intravenous fluid replacement should be started. In most persons, saline 0.9% is started at 15 to 20 mL/kg/hour. Fluid status, cardiac status, urine output, blood pressure, and electrolyte levels should be monitored. Once the corrected sodium concentration is normal or high (> 135 mEq/L), the solution can be changed to saline 0.45%. Dextrose is added when the glucose level decreases to 200 mg/dL.

To further correct hyperglycemia, insulin should be added to intravenous fluids 1 to 2 hours after fluids are initiated. An initial bolus of 0.1 units/kg should be given with an infusion of 0.1 units/kg/hour. Glucose level should decrease by about 50 to 70 mg/dL/hour, and the insulin infusion should be adjusted to achieve this goal.

Once the glucose level decreases to 200 mg/dL, the insulin infusion rate should be decreased to 0.05 to 0.1 units/kg/hour, and dextrose should be added to the intravenous fluids to maintain a glucose level between 150 and 200 mg/dL.

Subcutaneous insulin is not an appropriate initial treatment for DKA. A sliding scale of insulin would be appropriate following stabilization of the patient. Intravenous insulin bolus of regular insulin 0.15units/kg is not an appropriate initial treatment for DKA, given the need for restoration of circulating volume.

References:

Crandall J, Shamoon H. Diabetes mellitus. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016: 1527-1548.

Westerburg D. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013;87(5):337-346.

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