Case Conclusion — Retching Patient With Diabetes June 15, 2014
Posted by Andy Jagoda, MD in: Hematologic/Allergic/Endocrine Emergencies , trackback
Case Recap: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.
Conclusion: You ordered the appropriate tests for the first patient, the 26-year-old woman who was vomiting and sleepy, and discovered that her serum beta-hydroxybutyrate was 4 times normal. You asked the nurse to start the normal saline IV, and the patient received several liters prior to the lab tests returning. The tests showed that she had a serum potassium of 5.8 mEq/L, so you initiated the insulin drip at 0.14 units/kg/h and decided to forgo the insulin bolus, based on your recent reading about insulin in DKA. Since the patient’s bicarb was 9 mEq/L, you decided to admit her to the ICU. Unfortunately, there were no ICU beds, so for the next 8 hours you managed the patient in the ED. When her serum glucose approached 200 mg/dL, you changed to D5 half-normal saline for the fluid infusion, and decreased the insulin infusion to 0.04 units/kg/h. By the time she went up to the ICU, her gap had decreased from 29 to 19 mEq/L and her bicarbonate had increased to 18 mEq/L. She had an unremarkable course in the ICU, was eventually transferred to the floor, and by her fourth day in the hospital, was able to be safely discharged.
Thank you to everyone who participated in this month’s challenge!
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