Erin Baas
KNH 413
Case Study: Diabetic Ketoacidosis
Questions:
1. There are precipitating factors for diabetic ketoacidosis. List at least seven possible factors.
a. Some precipitating factors for DKA are infections, intercurrent illnesses, psychological
stress, poor compliance with therapy, alcohol/drug abuse, pancreatitis, and trauma.
(http://spectrum.diabetesjournals.org/content/15/1/28.full)
2. Describe the metabolic events that led to the symptoms associated with DKA.
a. DKA is characterized by hyperglycemia, metabolic acidosis, and increased total
body ketone concentration. Ketoacidosis results from the lack of, or ineffectiveness
of, insulin with concomitant elevation of counter-regulatory hormones including
glucagon, catecholamines, cortisol, and growth hormone. This leads to altered
glucose production/disposal and to increased lipolysis and production of ketone
bodies.
(http://spectrum.diabetesjournals.org/content/15/1/28.full)
3. Asses Susan’s physical examination. What is consistent with diabetic ketoacidosis? Give the
physiological rationale for each that you identify.
a. Susan is has fatigue, nausea, vomiting, tachycardia, high blood glucose, and overall
looks tired. These are all symptoms consistent with DKA.
(http://www.mayoclinic.com/health/diabeticketoacidosis/DS00674/DSECTION=symptoms)
4. Examine Susan’s biochemical indices both in the chemistry section and in her ABG report.
Which are consistent with DKA? Why?
a. The indices consistent with DKA in Susan’s ABG report are her low pH, CO2, and
HCO3- levels. Her high potassium, PO4, osmolality, glucose, BUN, creatine, and
HbA1c levels are the biochemical indices consistent with DKA.
5. If Susan’s symptoms were left untreated, what would happen?
a. Leaving symptoms of DKA untreated could be fatal for Susan or any individual.
(www.diabeteslibrary.org/PrintArticle.aspx?ArticleID=655)
6. Assuming Susan’s SMBG records are correct, what events seem to have precipitated the
development of DKA?
a. When Susan’s period was ending, her blood glucose levels were really high. Following
the end of her period, she had her birthday and then a volleyball tournament. During her
birthday and volleyball tournament she may have most likely been consuming more
carbohydrates than normal.
7. What, if anything, could Susan have done to avoid DKA?
a. Susan could have monitored her insulin level better and increased her dose. Also, if she
consumed alcohol on her birthday, should could have refrained from doing so.
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?
a. An IV piggyback is a way to administer medication through an intravenous tube that
is inserted into a patient’s vein. Tagamet is a type of medication called histamine
H2-antagonists. It inhibits the action of histamines on the acid producing cells of the
stomach and reduce stomach acid.
(http://www.wisegeek.com/what-is-an-iv-piggyback.htm)
(http://www.medicinenet.com/cimetidine/article.htm)
9. The Diabetes Control and Complications Trial was a landmark multi-center 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.
a. Intensive insulin therapy is a comprehensive system of diabetes management with the
patient and management as partners. The system is directed at improving glycemia and
the patient’s well-being. Conventional insulin therapy is a treatment option in insulin
dependent type 2 diabetic patients. Patients inject premixed human insulin before
breakfast and dinner and follow individually adjusted diet plans with fixed amounts of
carbs.
(http://care.diabetesjournals.org/content/13/12/1265.abstract)
(http://care.diabetesjournals.org/content/30/12/3031.full)
10. List the microvascular and neurologic complications associated with type 1 diabetes.
a. Microvascular complications associated with type 1 diabetes include diabetic
retinopathy, aldose reductase, advanced glycosylated end products, oxidative stress,
growth factors, proliferative retinopathy, and diabetic nephropathy. Neurologic
complications associated with type 1 diabetes include peripheral neuropathy, diabetic
neuropathy, numbness, burning, tingling, and sensory loss.
(http://clinical.diabetesjournals.org/content/26/2/77.full)
11. What are the advantages of intensive insulin therapy?
a. Intensive insulin therapy can prevent or slow the progression of long-term diabetic
complications. It can reduce the risk of eye damage, nerve damage, and prevent or
slow the progression of kidney disease. It can also help to boost overall energy.
(http://www.mayoclinic.com/health/intensive-insulin-therapy/DA00088)
12. What are the risks of intensive insulin therapy (tight control)?
a. Depending on the characteristics of the intensive insulin therapy protocol, it can
cause hypoglycemic episodes, especially in neurocritical care patients.
(http://www.ncbi.nlm.nih.gov/pubmed/21593693)
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?
a. Candidates for intensive insulin therapy should be adults, not children or the elderly.
They should be without heart disease, blood vessel disease, and/or severe diabetes
complications.
(http://www.mayoclinic.com/health/intensive-insulin-therapy/DA00088)
14. Explain how an insulin pump works. Is susan a candidate for an insulin pump?
a. Insulin pumps deliver rapid or short acting insulin 24 hours a day through a catheter
placed under the skin. The insulin doses are separated into basal rates, bolus doses to
cover carbohydrate in meals, and correction or supplemental doses. Based on
Susan’s current situation, I would say she is a good candidate for an insulin pump, as
it will help her to take better care of herself on a daily basis.
(http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/insulin/insulin-pumps-how-do-insulin.html)
15. How would you describe CHO counting to Susan and her family?
a. Carbohydrate counting is a meal planning technique for managing your blood
glucose levels. Foods containing carbs raise blood glucose levels. Keeping track of
how many carbs you take in and setting a limit for your maximum amount to eat will
help keep blood glucose levels in a safe range. Knowing how many carbohydrates
are in different types of foods will allow for carbohydrate counting.
(http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting/)
16. How is CHO counting used with intensive insulin therapy?
a. CHO counting helps those with intensive insulin therapy to modify their mealtime
dose or bolus of insulin to cover the amount of CHO eaten at a meal.
(http://www.diabetesselfmanagement.com/Articles/DiabetesDefinitions/carbohydrate_counting/)
17. Estimate Susan’s daily energy needs using the Harris-Benedict equation.
a. Harris-Benedict equation
= 655 + (9.56 x weight) + (1.85 x height) - (4.68 x age)
= 655 + (9.56 x 57.2) + (1.85 x 160.02) - (4.68 x 16)
=655 + (546.8) + (296.1) - (74.88)
=1,423 kcals
Activity factor = 2.0
= 1,423 x 2
= 2,846 kcals = 2,800 - 2,900 kcals/day
18. Using the 1-week food diary from Susan, calculate the average amount of CHO usually
consumed each meal and snack.
a. Grams CHO breakfast = 105 grams
b. Grams CHO lunch = 55 grams
c. Grams CHO snack = 30 grams
d. Grams CHO dinner = 75 grams
e. Grams CHO HS = 45 grams
19. After you have calculated Susan’s usual CHO intake from her food record, develop a CHOcounting meal plan that she could use. Include menu ideas.
Meal
CHO
Ideas
Breakfast
3-4 CHO choices
Cereal, milk, banana
Lunch
3-4 CHO choices
Snack
1-2 CHO choices
Sandwich with deli meat, fruit
item, vegetable item
yogurt, crackers, apple
Dinner
3-4 CHO choices
Snack
1 CHO choice
grilled chicken breast, salad,
red skin potatoes
Sorbet, piece of fruit
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?
a. Stevia is a novel sweetener and is approved by the FDA. Novel sweeteners are those
that are combinations of different types of sweeteners, which is turn makes they hard to
place in one particular category of sweeteners. Susan and her mom would need to make
sure the stevia they choose to use is highly refined, as this is the type of stevia the FDA
has approved. Stevia, along with other artificial sweeteners are good alternatives to sugar
for those with diabetes since they lack carbohydrates and therefore do not raise blood
sugar levels. I would also make sure to tell Susan and her mother to not use stevia or any
other artificial sweetener in excess, as this could potentially be harmful to the body.
(http://www.mayoclinic.com/health/artificial-sweeteners/MY00073)