Question

Meet your patient  J.S.

• Mr Singh., a 44-year-old male, was admitted to the emergency department after he was found comatose in his apartment by his wife. He was diagnosed with diabetes mellitus (Type 2) just 11 months ago andhas been taking 48 U of insulin daily: 12 U of regular insulin plus 20 U of NPH before breakfast, 8 U of regular insulin before dinner, and 8 U of NPH at bedtime.
• Mr. Singh and his family moved to Toronto from Ajax 18 months ago and works as a part-time mechanic in Jiffy Lube, likes to relax after work and has never been involved in any regular activities or organized sports. Mr. Singh weighs approximately 95 kg. and 175 cm.
• He has has two sons aged 19 and 20 living at home.
• Mr. Singh has a history of flu for 1 week with vomiting and anorexia.  
• Stopped taking insulin 2 days ago when he was unable to eat.

Physical Examination

Objective Data:

• Breathing is deep and rapid
• Acetone smell on breath
• Skin flushed and dry
• BP 98/50, RR 32, Pulse 82, T. 37
• Unconscious
• O2 sats-94 % room air

Subjective Data:

• Mrs. S. found husband “blacked out on the floor of their apartment, did not know how long he had been unconscious.
• Called 911 immediately.

Physician’s orders for Mr. Singh.

• Blood work includes: Blood glucose, CBC, Ketones, pH, electrolytes, BUN, Arterial blood gases, Urinalysis (SG, pH, glucose, ketones)
• Initial IV R/L, 0.45% or 0.9% NS at 300mL/hr to restore urine output to 30 to 60 mL/hr and raise blood pressure.
• When blood glucose levels approach 14 mmol/L, 5% dextrose is added to the fluid regimen
• IV insulin 1 unit/minute, titrate as glucometer readings improve
• Monitor blood glucose levels q.1.h.
• ECG monitoring
• Oxygen (2-5 litres) via Nasal Prongs

Lab Results for Mr. Singh.

• Blood glucose:730 mg/dl (40.5 mmol/L)
• Arterial Blood Gases pH 7.26, PCO2 32, HCO3 16
• CBC: Hgb 124 mmol/L, Hct 75%, Creatinine 11.2 mcmol/L., BUN 6.5 mmol/L.
• Electrolytes: Potassium 3 mmol/L, Sodium 128 mmol/L, Chloride 95 mmol/L., Magnesium 0.65 mmol/L,
• Urinalysis: Ketones positive, pH 4.3, SG-1.039, glucose positive.
• ECG normal sinus rhythm

Critical Thinking Questions:

1. Explain the lab values. What does your clinical judgment suggest to you once you receive the results?
2. What factors precipitated this patient's DKA?
3. Explain physician’s orders.
4. What distinguishes this case history from one of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or hypoglycemia?
5. What teaching should be done with this patient and his family?

Answer 1

Explain the lab values. What does your clinical judgment suggest to you once you receive the results?

answer:

The interpretation of the lab values is as listed-

• Blood glucose:730 mg/dl (40.5 mmol/L)-suggestive of hyperglycemia.(normal<100mg/dl fasting;<140mg/dl 2 hours after meals)
• Arterial Blood Gases pH 7.26, PCO2 32, HCO3 16--metabolic acidosis(decrease pH<7.4 hence acidosis,decrease bicarbonate=hence metabolic acidosis (normal bicarbonate=22-26meq/l)
• CBC: Hgb 124 mmol/L, Hct 75%,.--elevation of haematocrit (38-48%normal )suggests dehydration and hemoconcentration. BUN 6.5 mmol/L.-normal levels(2.5-7.1mmol//L)
• Electrolytes: Potassium 3 mmol/L==hypokalemia Sodium 128 mmol/L, hyponatremia(may be dilutional due to hyperglycemia} Chloride 95 mmol/L., Magnesium 0.65 mmol/L,==hypomagnesemia ---due to diabetes,polyuria.
• Urinalysis: Ketones positive, pH 4.3, SG-1.039, glucose positive.-suggestive of ketonuria,glucosuria
• ECG normal sinus rhythm

Explanation of the laboratory values and reports: The report of the patient is characterized by blood sugar levels which are higher than 250 milligram per decilitre, presence of ketonuria and glucosuria, electrolyte imbalances like hyponatremia,hypomagnesemia and hypokalemia .ABG shows  the metabolic picture of acidosis and bicarbonate level of less than 18 meq/liter.Since the laboratory investigations in the patient manifest hyperglycemia ,ketonuria, metabolic acidosis with electrolyte imbalance; the diagnosis is that of diabetic ketoacidosis with electrolyte imbalance.

What does your clinical judgment suggest to you once you receive the results?

answer:

The clinical judgement on receiving the results suggests that the patient is suffering from diabetes ketoacidosis and needs urgent insulin therapy and intravenous fluids and electrolytes in order to correct the blood glucose levels ,dehydration and electrolyte imbalances respectively and bicarbonate supplementation for the acidosis along with electrolytes correction. It explains that the diabetic ketoacidosis could be the reason for the unconsciousness of the patient, The laboratory findings confirm the diagnosis and press the need for emergency therapy for diabetes ketoacidosis.

Since the patient is tachypneic and oxygen saturation is a 94 %, clinical judgement also suggests that an x-ray of the chest must be done to rule out pneumonia in view of one week history of flu.

What factors precipitated this patient's DKA?

answer:

The infection of flu that the patient suffered, the decreased food intake along with the flu,vomiting and anorexia and the stoppage of insulin for two days precipitated the diabetic ketoacidosis.

Diabetic ketoacidosis is precipitated by the excessive synthesis of ketone bodies from the fatty acids due to the starvation causing ketonemia,ketonuria and acidosis and  lack of insulin in the body leading to elevation of the blood sugar levels caused by sudden stoppage of insulin generally precipitated by infections in the patient which leads to vomiting ,anorexia,decrease in food intake and decrease/stoppage of the insulin intake.

Explain physician’s orders.

answer:

Analysis of the physician Orders and the explanation is given below:

The following are included in the physician's orders and their rationale of administration is given alongside

• Initial IV R/L, 0.45% or 0.9% NS at 300mL/hr to restore urine output to 30 to 60 mL/hr and raise blood pressure.-for correction of dehydration and low blood pressure
• When blood glucose levels approach 14 mmol/L, 5% dextrose is added to the fluid regimen-to prevent hypoglycemia
• IV insulin 1 unit/minute, titrate as glucometer readings improve-to decrease blood sugar levels.
• Monitor blood glucose levels q.1.h.--to monitor the levels and prevent hypoglycemia
• ECG monitoring-to rule out arrythmias.
• Oxygen (2-5 litres) via Nasal Prongs-in view of low oxygen saturation and tachypnea.

Explanation: Since the patient is hypotensive and has a blood pressure of 90 / 50 mmHg,the physician has ordered intravenous fluid with ringer lactate or normal saline at 300ml/hr to restore his blood pressure and to correct his dehydration status and achieve a urine output of 30 to 60 litres per minute. The insulin drip of one unit per minute has been prescribed in order to take care of the hyperglycemia that the patient is suffering from as the blood glucose levels are 730mg/dl.Monitoring of the blood glucose while on insulin therapy is recommended in order to prevent the occurrence of a sudden hypoglycemia or over correction and monitor the therapy effectively. Once the glucose levels reach the normal. 5% dextrose has been added to the fluid regimen in order to prevent hypoglycemia in the patient and maintain normal blood glucose levels. ECG monitoring has been asked for to rule out arrhythmias or bradycardia in view of metabolic acidosis. Oxygen supplementation has been given as a supportive therapy in view of the metabolic status and low oxygen saturation of the patient.This explains the physician's orders.

What distinguishes this case history from one of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or hypoglycemia?

answer:

The presence of acetone smell in breath and the positivity of urine for ketones along with sudden stoppage of insulin following flu infection distinguishes this case from that of hyperosmolar hyperglycemic nonketotic or hypoglycemic coma.

Unconsciousness with hyperglycemia with acetone smell and ketonuria in a known case of diabetes differentiates the unconsciousness to be caused from diabetic ketoacidosis in this case history.

The history in diabetic ketoacidosis is that of starvation which lead to generation of excessive ketone bodies due to fatty acid utilisation and causing ketonemia,ketonuria and acidosis while that in a hyperosmolar hyperglycemic nonketotic coma is generally that of insufficient insulin therapy. The history in hypoglycemic coma is at of administration of insulin which is not followed by adequate food intake or increased exercise or exertion leading to excess glucose utilisation resulting in hypoglycemia.

What teaching should be done with this patient and his family?

answer:

1.Teaching/explanation of the pathophysiology of the diabetic ketoacidosis and the reason for the unconsciousness in detail with its relation to the stoppage of the insulin therapy with an aim of patient education and to prevent future episodes.

2. Advising and teaching the patient and his family not to stop the insulin suddenly without physician advice in any situation.

3 Home glucose monitoring with Glucometer has to be taught to the patient and his family in order to be able to effectively manage insulin therapy at home without episodes of hypoglycemia or hyperglycemia.

4. The patient has to be taught about self glucose monitoring on a regular basis and more so if the patient has any disease or infection which alters appetite/intake and has to be educated about the insulin dose adjustment as per his carbohydrates intake.

5.The patient and his family have to be educated to seek physician consultation early in case of infection and decreased food intake for adjustment of insulin doses.

6.The patient and his family teachings include the maintainence of healthy lifestyle along regular exercise and maintenance of ideal body weight and diabetic diet The importance of maintaining normal blood glucose levels and the complications of diabetes must be explained to them thoroughly.

7.It must be ensured that the patient has learnt the procedure of the home blood glucose monitoring and insulin dose adjustments as per his dietary carbohydrate intake.

8.Education about the annual flu vaccine adminstration must be given.