1CASE STUDY: THE MANAGEMENT

1 OF DKA
Med Pharm 501/801, Fall2005

Objective: This case is designed to give you experience in applying your knowledge of the
pathophysiology of diabetic ketoacidosis and pharmacologic agents (insulin, electrolytes, and
intravenous fluids) used to treat patients with this condition. To prepare for this exercise, you
should review the pathophysiology of diabetes mellitus and diabetic ketoacidosis.

LEARNING OBJECTIVES
When you have completed this exercise, 2you should be able to:

Describe the changes in fatty acid metabolism that lead to the development of
ketoacidosis.

Understand how ketoacidosis and the hyperglycemia of poorly controlled diabetes

mellitus can lead to the loss of sodium, potassium, bicarbonate, phosphorus, and
other important electrolytes.

Outline the general strategy for giving insulin, fluids, and electrolytes to restore
the patient to normal metabolism and fluid balance.
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CASE HISTORY

The patient is a 23 year old male college student who was discovered lying on the floor
of his apartment unconscious by a friend. The patient was transported to the hospital by
paramedics, who noted that the patient was breathing very deeply and appeared to be dehydrated.
The friend said that the patient had developed a respiratory infection with a cough 4 days earlier
and had been seen at the Student Health Center. The patient was advised to go home, rest, and
drink lots of fluids.

On admission to the Emergency Room, the students vital signs were P 120 regular, BP
110/65, R 32, and T 37. He was comatose, barely responding to painful stimuli. His skin and
mucous membranes appeared to be dry and dehydrated. The nurse commented that his breath
had a peculiar odor, and he appeared to be hyperventilating. However, he had normal breath
sounds and the cardiac exam was unremarkable. A blood specimen was drawn for stat
laboratory studies, and a catheter was placed in his bladder, yielding 300 cc of urine. A drop of
blood was tested with a glucometer and indicated greater than 450 mg/dl.

1. What are the clinical findings that establish that this patient has diabetic ketoacidosis?
Why is he breathing so deeply? How did he become so dehydrated? What is the most
important first step in treatment of this condition?

2. What are the metabolic steps that lead to the elevated levels of ketoacids in the
circulation and urine of this patient? What causes the acidosis? Since he had not been
eating, why is he hyperglycemic?
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The patient is given saline at a rate of 1000 ml/hr, and a bolus of 15 units of regular
insulin is given through the intravenous access. A bottle containing insulin in 250 ml of normal
saline is piggybacked into the intravenous line and the infusion rate adjusted to administer the
insulin at a steady rate of 7 units/hr. The patient is transferred to the Intensive Care Unit. The
laboratory reports that the blood glucose of 650 mg/dl, the Na 138, K 6.4, Cl 103, and HCO 3 6.
An ECG reveals sinus tachycardia with tall T-waves. Four hours later, an ECG rhythm strip
indicates that the T-waves have almost disappeared and u-waves are now apparent. Repeat
laboratory studies indicate that the serum Na is 142, K 3.1, Cl 109, and HCO3 10.

3. How much NaCl is there is a liter of normal saline? Why is the serum K elevated
initially? Why does the serum K fall during treatment? What explains the increase in the
serum HCO3? Should NaHCO3 be given intravenously to increase the rate of return of the
serum HCO3 to normal? What happens to the serum phosphorus during treatment of
diabetic ketoacidosis?

After 6 hours of treatment the intravenous fluids were changed to half-normal saline with 30 meq
of potassium chloride per liter. The next morning the patient was conscious but complained of
nausea and vague abdominal pain. The serum HCO 3 had risen to 16. The blood glucose had
decreased to 150 mg/dl.

4. Why was the intravenous fluid changed to half-normal? Since the blood glucose has
fallen to almost normal levels, should the rate of insulin infusion be decreased? When can
the patient be given something to eat and drink? When can the patient be switched from
intravenous insulin to subcutaneous doses of insulin
5 to maintain normal blood glucose?

Later in the afternoon of the second hospital day, the patient complained of being hungry and
wanting something to drink. He tolerated sips of water and soup, and he was given a small
supper. The following morning he was given 20 units of NPH insulin at 7:00 am before
breakfast and his insulin drip was discontinued at 11:00 am. The nurse Certified Diabetes
Educator came and instructed the patient regarding diabetes mellitus and how to inject insulin
and check blood glucose by fingerstick. The patient was discharged with instructions to take a
mixture of NPH, 8 units, and regular insulin, 6 units, before supper. He was given an
appointment to the Diabetes Clinic for further education and monitoring of his condition.

5. Why was the intravenous insulin continued for 4 hours after giving the patient NPH
insulin on the third hospital day? How did the physicians decide on the doses of NPH and
regular insulin to give to this patient? What else about managing diabetes mellitus did this
patient have to learn?