Katie Arlinghaus
KNH 413; Matuszak
Case Study #2
February 18, 2014
Case 27: Type 1 Diabetes Mellitus with Diabetic Ketoacidosis
1. There are precipitating factors for diabetic ketoacidosis. List as least seven possible
factors.
Precipitating factors may include infection, insulin omission, inadequate insulin therapy,
discontinuation of insulin use, myocardial infarction, cerebral edema, pancreatitis, stroke,
trauma, and alcohol and drug abuse.
(http://www.aafp.org/afp/2005/0501/p1705.html,
http://www.ima.org.il/FilesUpload/IMAJ/0/38/19466.pdf)
2. Describe the metabolic events that led to the symptoms associated with DKA.
Diabetes mellitus is the underlying cause of DKA. The pathogenesis of DKA involves
insulin deficiency and an increased production of catabolic hormones such as glucagon,
cortisol, catecholamines, and growth hormone. Insulin deficiency can come from lack of
insulin production or inadequate intake of prescribed insulin. The lack of insulin causes
hyperglycemia, which induces osmotic diuresis causing water and electrolyte loss.
Ketosis can occur when ketones are used as an alternative energy source. Ketosis causes
metabolic acidosis, which forces hydrogen ions into cells and displaces potassium ions
lost through urine and vomiting.
(https://www.clinicalkey.com/topics/endocrinology/diabetic-ketoacidosis.html)
3. Assess Susan’s physical examination. What is consistent with diabetic ketoacidosis?
Give the physiological rationale for each that you identify.
Susan’s dry membranes in her ears and nose and her intense thirst indicate dehydration.
This is a common symptom of DKA because the build up of ketones cause more water to
be drawn into the urine. Susan’s nausea and vomiting would only exasperate her
dehydrated state. Furthermore, Susan’s breathing difficulty and tachycardia can be
explained by DKA as well. The respiratory system has to compensate for her metabolic
acidosis. Her pulse increased because her blood pressure decreased. Finally, the acetone
smell of Susan’s breath is very telling of ketoacidosis as it is the smell of extra ketones,
extra acid.
(http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx)
4. Examine Susan’s biochemical indices both in the chemistry section and in her ABG
report. Which are consistent with DKA? Why?
Susan’s high K, PO4, osmolality, glucose, BUN, creatine, HbA1c, and low pH, CO2, and
HCO3- levels are consistent with her DKA diagnosis. The buildup of ketones disrupts her
electrolyte and acid-base balance. The extra acid is buffered by HCO3-, so its
concentration in the blood increases. The academia causes an increase in breathing rate
which decreases CO2.
(http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx)
5. If Susan’s symptoms were left untreated, what would happen?
If Susan’s symptoms were left untreated, the number of ketones in her blood would
increase, disrupting the normal functioning of many parts of her body. It can cause
dehydration, kidney failure, coma, respiratory distress syndrome, or even swelling of the
brain.
(http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx)
6. Assuming Susan’s SMBG records are correct, what events seem to have precipitated the
development of DKA?
If her SMBG records are correct, it seems that her volleyball tournament and her birthday
precipitated her development of DKA. Although it isn’t completely understood, many
women with diabetes demonstrate significant changes in glucose control associated with
their menstrual cycle.
(http://www.ncbi.nlm.nih.gov/pubmed/18414069)
7. What, if anything, could Susan have done to avoid DKA?
One of the main things she could have done to avoid DKA would have been to keep her
blood glucose levels consistent. This means taking her insulin, keeping her carbohydrate
intake consistent, and drinking more water. Although she says that she was following her
meal plan and prescription, her glucose levels were clearly not consistent. Perhaps her
plan needs to be changed, especially during times of high activity such as her volleyball
tournament. Her period may have also complicated matters. To prevent DKA, when she
begins to see her blood glucose levels raise she should check her ketone level.
(http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx)
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does “IV
piggyback” mean? What is Tagamet, and why has it been prescribed?
An IV piggyback is a device that allows various fluids to be given at different rates. The
mechanism that controls the rate of delivery is kept separate but the IV access line is
shared. This allows her to be given medicine on top of the general IV saline solution.
Tagamet is the brand name for cimetidine, which is used to decrease the amount of acid
in the stomach. This would help lower her pH, which were low according to her lab
values.
(http://www.rxlist.com/tagamet-drug.htm)
9. The Diabetes Control and Complications Trial was a landmark multicenter trial designed
to test the proposition that complications of diabetes mellitus are related to elevation of
plasma glucose. It is the longest and largest prospective study showing that lowering
blood glucose concentration slows or prevents development of complications common to
individuals with diabetes. The trial compared “intensive” insulin therapy (“tight
control”) with “conventional” insulin therapy. Define “intensive” insulin therapy.
Define “conventional” insulin therapy.
Intensive insulin therapy is an aggressive treatment approach designed to control your
blood sugar levels by administering frequent doses of insulin. It involves non-scheduled
meal times and up to 4 injections of insulin daily. Conventional insulin therapy is An
older method that intensive insulin therapy. It involves having scheduled meals with 2-3
injections of insulin daily.
(http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866)
10. List the microvascular and neurologic complications associated with type 1 diabetes.
Microvascular complications include: diabetic etinopathy, aldose reductase, oxidative
stress, growth factors, diabetic nephropathy, and proteinuria. Neurologic complications
include peripheral neuropathy, diabetic neuropathy, chronic sensorimotor distal
symmetric polyneuropathy, numbness, burning, tingling, electrical pain, and sensory loss.
(http://clinical.diabetesjournals.org/content/26/2/77.full)
11. What are the advantages of intensive insulin therapy?
Advantages to intensive insulin therapy include: preventing or slowing the progression of
long-term diabetes complications; reducing the risk of eye damage, reducing the risk of
nerve damage, slowing or preventing the progression of kidney disease, and help boost
the patient’s energy.
(http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866)
12. What are the risks of intensive insulin therapy (tight control)?
Risks of intensive insulin therapy include weight gain and low blood sugar.
(http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866)
13. Dr. Green consults with you, and the two of you decide that Susan would benefit from
insulin pump therapy combined with CHO counting for intensive insulin therapy. This
will give Susan better glycemic control and more flexibility. What are some of the key
characteristics of candidates for intensive insulin therapy?
Candidates for intensive insulin therapy should not be children or elderly, should not
frequently struggle with severe bouts of low blood sugar, do not have heart or blood
vessel disease, and should be active. Susan meets these criteria.
(http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensive-insulintherapy/ART-20043866)
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
Insulin pumps release insulin into the body through a plastic tube that is placed under the
skin of the abdomen. The pump delivers continuous infusion of short-acting insulin and
bolus before meals. The pump is the size of a charger and is operated with batteries. Of
possible treatment options, the insulin pump most closely mimics natural insulin
secretion. Base on the patient history provided, Susan would be a candidate for an
insulin pump.
(Page 489, http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensiveinsulin-therapy/ART-20043866)
15. How would you describe CHO counting to Susan and her family?
I would explain that CHO counting is a meal planning approach that concentrates on the
total amount of carbohydrate eaten at meals and in snacks. It is based on research that
demonstrates how consistent intake of a wide variety of carbohydrates results in similar
postprandial glucose responses. Awareness of carbohydrate intake and distribution has
been shown to improve metabolic control. I would explain to them that she could look
on labels for total carbohydrate grams or use carbohydrate choices where one choice=15
grams carbohydrate.
(Page 492-493)
16. How is CHO counting used with intensive insulin therapy?
CHO counting is used with intensive insulin therapy by calculating the insulin-tocarbohydrate ratio to determine proper insulin dosages based on carbohydrate intake.
Generally 1 unit of rapid-acting insulin is taken for every 10-15 grams of carbohydrates.
This can be used as a starting point and then adjusted according to Susan’s SMBG
records.
(Page 493)
17. Estimate Susan’s daily energy needs using the Harris-Benedict equation.
655 + (9.56 x wt) + (1.85 x ht) – (4.68 x age)
655 + (9.56 x 57.2kg) + (1.85 x 160.02cm) – (4.68 x 16years)
655+ (546.832) + (296.037) – (74.88)
=1,422.989 kcal x 2.0 physical activity/stress factor
= 2,845.978 kcal
(Page 241)
18. Using the 1-week food diary from Susan (next page), calculate the average amount of
CHO usually consumed each meal and snack.
Breakfast: (112+112+97+112+112+102+102)/7days= average of 107 grams CHO
Lunch: (115+115+100+102+115+120+120)/7days= average of 112 grams CHO
Snack: (85+30+55+30+45+45+15)/7days= average of 43 grams CHO
Dinner: (325+72+115+120+140+100+120)/7days= average of 142 grams CHO
HS: (15+15+55+15+85+65+65)/7days= average of 45 grams CHO
(Page A109-A123)
19. After you have calculated Susan’s usual CHO intake from her food record (question 18),
develop a CHO-counting meal plan that she could use. Include menu ideas.
Daily total: 391g CHO; 142g protein; 79g fat; 2,845 calories
2,845kcal*.55=1,564kcal/4kcal per gram CHO=391g CHO/15g per serving=26 CHO
choices
2,845kcal*.2=569kcal/4kcal per gram protein=142g Protein/7g per serving=21 servings
2,845kcal*.25=711kcal/9kcal per gram fat=79g Fat/5g per serving=16
Time
7:00-8:00am
CHO Choice or Grams CHO
6 CHO choices or 90 g CHO
4 oz meat/meat substitutes
3 servings fat
3 CHO choices or 60 g CHO
2 oz meat/meat substitutes
2 servings fat
Menu Ideas
1 cup of Cheerios with ½ cup
2% milk, 1 banana with 1 T
peanut butter
3 oz pretzels with peanut
butter or hummus, or a yogurt
with fruit and nuts
1:00-2:00pm
6 CHO choices or 90g CHO
5 oz meat/meat substitutes
3 servings fat
4:00-5:00pm
3 CHO choices or 60 g CHO
2 oz meat/meat substitutes
2 servings fat
6 CHO choices or 90 g CHO
6 oz meat/meat substitutes
3 servings fat
Turkey sandwich: 2 slices
whole wheat bread, 2 oz deli
turkey, lettuce, tomato, 2 tsp
mayonnaise, mustard
1 medium apple, 1 oz carrot
sticks 2 T fat-free Ranch
dressing
Graham crackers or apples
with peanut butter or 2 apples
10:00-10:30am
6:30-7:30pm
9:00-10:00pm
2 CHO choices or 60 g CHO
2 oz meat/meat substitutes
3 servings fat
3 oz chicken breast- grilled
with bbq sauce, side salad
with fat-free dressing, 1 small
baked potato with sour cream
and cheese, 1 8-oz glass of 2%
milk, 1 small slice of cake
½ Cup Ice Cream with
chopped nuts, fruit topping, in
a waffle bowl
20. Just before Susan is discharged, her mother asks you, “ My friend who owns a health
food store told me that Susan should use stevia instead of artificial sweeteners or sugar.
What do you think?” What will you tell Susan and her mother?
I would tell Susan and her mother that Stevia is a non-caloric sweetener that is 20-30
times sweeter than sugar, however it still has carbohydrates. Some people do not like the
after taste of Stevia. There are questions about the toxicity of Stevia. Until 2008, the
FDA allowed it to only be sold as a dietary supplement. It has been given GRAS
(generally recognized as safe) status.
(http://www.eatingwell.com/nutrition_health/nutrition_news_information/is_stevia_safe)
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