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Zorluk: OrtaEndocrinology and Metabolism

A 2222-year-old man with a history of type 1 diabetes mellitus is brought to the emergency department due to lethargy, abdominal pain, and recurrent vomiting for the past 2424 hours. He recently had a viral respiratory tract infection. Vital signs show a temperature of 37.2∘C37.2^{\circ}\text{C} (99.0∘F99.0^{\circ}\text{F}), blood pressure of 90/6090/60 mm Hg, pulse of 122122/min, and respirations of 2828/min with deep, sighing breathing. Point-of-care blood glucose is 520520 mg/dL. Intravenous access is established. Arrange the following acute management steps in the most appropriate chronological order.

  1. 1Administer a rapid infusion of 0.9%0.9\% sodium chloride
  2. 2Obtain serum potassium concentration
  3. 3Initiate continuous intravenous regular insulin
  4. 4Add 5%5\% dextrose to the intravenous fluids

Cevap

The correct sequence is: rapid fluid resuscitation with normal saline, followed by establishing the serum potassium level, then initiating intravenous insulin, and finally adding dextrose to the fluids once glucose falls below 200200 mg/dL.
The standard protocol for DKA management prioritizes addressing life-threatening volume depletion first. Therefore, a rapid infusion of 0.9%0.9\% sodium chloride is the initial step. Next, because total body potassium is depleted in DKA and insulin drives potassium intracellularly, the serum potassium level must be obtained to ensure it is >3.3> 3.3 mEq/L before starting insulin. Once potassium is confirmed safe, an intravenous regular insulin infusion is initiated to resolve the ketoacidosis. Finally, when the blood glucose drops to 200200 mg/dL, 5%5\% dextrose must be added to the intravenous fluids to prevent hypoglycemia while the insulin infusion continues in order to close the anion gap.

Adım Adım Çözüm

1
Assess volume status and provide initial fluid resuscitation.
Administration of 0.9%0.9\% sodium chloride restores intravascular volume.
Patients with DKA have profound fluid deficits (often 33 to 66 liters) due to osmotic diuresis. Reversing hypovolemic shock is the most immediate priority.
2
Evaluate baseline electrolyte levels, particularly potassium.
Serum potassium concentration is ascertained.
Total body potassium is depleted in DKA despite often normal or high serum levels. Because insulin shifts potassium into cells, it is unsafe to administer insulin without knowing if the patient requires concurrent potassium repletion.
3
Administer insulin therapy.
Continuous intravenous regular insulin is started.
Insulin stops ketogenesis, allowing the anion gap acidosis to resolve.
4
Adjust fluid composition based on glucose response.
5%5\% dextrose is added to intravenous fluids.
Once blood glucose reaches 200200 mg/dL, dextrose prevents hypoglycemia, allowing the insulin infusion to continue until ketones are cleared and the anion gap closes.

Anahtar Kavram

Chronological Management of Diabetic Ketoacidosis (DKA)
Tahmini Süre:1m 30s
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Konular

Endocrinology and Metabolism

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