Robert Tempero
last written: July 2011, David LaPierre
last reviewed:
introduction
Robert is a 34 year-old man with Type I diabetes. He has poor control and has been admitted many times for sugars that have been too high and too low.
He comes to the emergency department with abdominal pain, nausea, and fatigue.
The emergency room physician checks his sugars, which are 38 mmol/L. He is therefore admitted to the medicine floor.
What are your immediate steps?
Assess and treat ABCs:
- oxygen
- IV access
- consider intubation
Fluid recuscitate with normal saline, using 15-20 ml/kg/hr bolus and then 1/2 NS 4-14 ml/kg/hr.
Provide 20meq/L KCl to 1/2 NS when K <5.0
What do you monitor?
Monitor the following:
- constant cardiac tracing until pH >7.3
- hourly:
- electrolytes
- bicarbonate
- ABG
- anion gap
- glucose
- serum osmolality
- ketones
How do you dose insulin?
Begin with 0.15 units/kg IV push insulin R.
Provide 0.1 units/kg/hr.
Titrate to anion gap; if gap is still up, double rate.
Aim for blood glucose of 10-20 mM on first day. Aim for a drop of <5mM/hr.
How do you treat his acidosis?
Consider 1-2 amps HCO3 push if pH is <7.0.
When do you resume SC insulin?
Switch to SC insulin when:
- anion gap is normalized
- insulin requirements are reasonable
- patient is hungry
- in the morning
ensure SC dosing and IV dosing overlap by at least one hour.
When do you provide glucose?
Provide glucose (in IV #3) when BG is <15 mM. Run D5W or D10W.
Robert recovers quickly over the next few days and is discharged into the care of his family doctor. You hope he will be more diligent with his sugar control.
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