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Zorluk: OrtaEndocrinology and Metabolism

A 2222-year-old man with type 11 diabetes mellitus is brought to the emergency department due to nausea, vomiting, and confusion for the past 2424 hours. He has not taken his insulin for 22 days. Vital signs show blood pressure 90/6090/60 mm Hg, heart rate 124124/min, and respiratory rate 2626/min with deep, sighing breaths. Laboratory evaluation reveals a serum glucose of 580580 mg/dL, potassium of 4.94.9 mEq/L, bicarbonate of 1111 mEq/L, and an arterial pH of 7.187.18. Serum ketones are strongly positive. Arrange the following steps in the most appropriate sequence for the acute management and resolution of this patient's condition.

  1. 1Administer an intravenous bolus of 0.9% normal saline
  2. 2Initiate a continuous intravenous regular insulin infusion
  3. 3Add 5% dextrose to the intravenous fluids
  4. 4Administer subcutaneous long-acting insulin
  5. 5Discontinue the continuous intravenous regular insulin infusion

Cevap

The correct sequence for DKA management is: IV normal saline, followed by IV regular insulin, adding dextrose when glucose drops, administering subcutaneous insulin once the gap closes, and finally stopping the IV insulin after a brief overlap.
The standard protocol for DKA resuscitation follows a strict physiological sequence. First, intravascular volume must be replaced with normal saline to prevent hemodynamic collapse. Second, once potassium is confirmed adequate, a continuous IV insulin infusion is started to halt ketone production. Third, because glucose drops faster than ketones clear, dextrose must be added to the IV fluids once glucose reaches 200-250 mg/dL to prevent hypoglycemia while the insulin infusion continues. Fourth, once the anion gap closes, subcutaneous basal insulin is administered. Finally, the IV insulin is discontinued 1-2 hours later to allow the subcutaneous depot to absorb, preventing a gap in insulin coverage that would trigger rebound ketoacidosis.

Adım Adım Çözüm

1
Administer intravenous fluids (0.9% normal saline).
Restoration of intravascular volume and renal perfusion.
Patients with DKA have significant osmotic diuresis leading to profound dehydration. Administering insulin first would drive glucose and water into cells, potentially causing cardiovascular collapse.
2
Start continuous intravenous regular insulin.
Suppression of lipolysis and ketogenesis.
After confirming potassium is ≥3.3 mEq/L (the patient's is 4.9 mEq/L), insulin is required to drive potassium and glucose into cells and stop ketone production, resolving the anion gap acidosis.
3
Add 5% dextrose to intravenous fluids.
Prevention of severe hypoglycemia.
Serum glucose typically normalizes faster than the ketoacidosis resolves. When glucose falls to ≤200-250 mg/dL, dextrose is added so insulin can be safely continued until the anion gap closes.
4
Give subcutaneous long-acting insulin.
Establishment of basal insulin coverage.
Once the anion gap closes (≤12 mEq/L) and the patient tolerates oral intake, transition to a subcutaneous regimen begins.
5
Discontinue the IV insulin infusion.
Safe transition off continuous infusion without rebounding.
IV regular insulin has a half-life of only minutes. It must overlap with the subcutaneous dose by 1-2 hours to prevent immediate recurrence of ketogenesis.

Anahtar Kavram

Stepwise acute management of Diabetic Ketoacidosis (DKA)
Tahmini Süre:1m 30s
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Konular

Endocrinology and Metabolism

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