Date: 10/18/2013 0900 Consult: Pharmacotherapeutic Plan for Acute Diabetes Ketoacidosis
Subjective
CC: "I felt weak and nauseated during softball practice. I checked my blood glucose and it read
'HI.'"
HPI: Mary McGee is a 21-year-old woman with a history of type 1 diabetes, diagnosed 3 years
ago. She is a college senior and plays softball. She started using an insulin pump approximately
6 months ago. She noticed she was unusually tired and short of breath at the beginning of her
practice and then began feeling weak and nauseated. She was also very thirsty during practice.
Her softball coach said she seemed "a little confused." She checked her insulin pump and
noticed the pump had become disconnected. She is unsure how long she has been without
insulin. She vomited x 2 since shortly thereafter and was transported via emergency medical
services to the emergency department.
PMH: Type 1 DM diagnosed 3 years ago
Meds: NovoLog 100 U/mL, per insulin pump. Basal rates: 0.6 U/h 0000–0300; 0.9 U/h 0300–
0700; 0.8 U/h 0700–1100; 0.7 U/h 1100–1730; 0.8 U/h 1730–0000. Correction factor: 1 U:40
mg/dL >120 mg/dL; Insulin:carbohydrate ratios: 1:10 insulin:carbohydrate before breakfast;
1:15 insulin:carbohydrate before lunch and dinner; Glucagon injection kit as needed
Allergies: NKDA
FH: Parents are alive and healthy. One twin sister who also has type 1 diabetes.
SH: College student; no tobacco, alcohol, or illicit drug use
ROS: Complains of blurry vision, lethargy, shortness of breath, nausea, polyuria, and polydipsia.
Denies constipation, diarrhea, and headache.
Objective
PE: Gen: WDWN Caucasian female appearing her stated age, with deep respirations, ketones on
her breath, and slurred speech; slightly confused, but responds appropriately to question
VS: BP 101/72, P 123, RR 32, T 37.0°C; Wt 56 kg, Ht 5'6″
HEENT: PERRLA, EOMI; mucous membranes are dry
Lungs: CTA, Kussmaul respirations
CV: S1 and S2 are normal without S3, S4, murmur or rub; RRR
MS/EXT: No edema, pulses 2+ throughout, mild calluses
Neuro: A & O x 3; DTRs 2+ throughout; feet with normal sensation and vibration
Labs: Na 136 mEq/L; K 4.8 mEq/L; Cl 101 mEq/L; CO2 10 mEq/L; BUN 23 mg/dL; SCr 1.4 mg/dL;
Glu 479 mg/dL; WBC 16.0 x 103/mm3 ; RBC 4.61 x 106/mm3; Hgb 14.2 g/dL ; Hct 40.7% ;
Platelets 239 x 103/mm3; Ketones Positive
ABG: pH 7.26; pCO2 21 mm Hg; pO2 128 mm Hg; HCO3 7.1 mEq/L; oxygen sat 97%; anion gap
25 mEq/L
IBW: 59.3kg CrCl: 56.2mL/min
UA: (+) Ketones; (+) glucose
Chest X-Ray: Normal
ECG: Sinus tachycardia
Assessment: MM presenting with s/sx of diabetic ketoacidoses and hyperglycemia likely due to
risk from type 1 diabetes and missed insulin medication. Goals of therapy include expansion of
intravascular and extravascular volume, restoration of renal perfusions, correction of acidosis,
Andrew Jung, Intern Pharmacist (777) 777-7777
Date: 10/18/2013 0900 Consult: Pharmacotherapeutic Plan for Acute Diabetes Ketoacidosis
dehydration, hyperosmolarity, fluid and electrolyte losses, and preventing further
complications. Consider long term goals of HbA1C less than 7% and fasting glucose of 70130mg/dL per ADA guidelines. Management of diabetic ketoacidosis (DKA) includes rapid
correction of fluid loss, insulin, potassium, and bicarbonate therapy. Per ADA guidelines, start IV
fluids using normal saline (0.9% NaCl) at a rate of 15-20mL/kg or 1-1.5L during the first hour. If
pt’s corrected sodium concentration is normal or elevated, use 0.45%NS at a rate of 414mL/kg/hr (250-500mL/hr). Use 0.9% NS if corrected sodium is low. Once serum glucose
reaches 200mg/dL, change to 5% dextrose with 0.45% NaCl at 150-250mL/hr. Glucose is added
to prevent hypoglycemia and the cerebral edema that can occur if the osmolality is reduced too
rapidly. Continuous IV infusion of regular insulin is preferred. Recommended bolus dose of
0.1unit/kg IV followed by a continuous infusion dose of 0.1unit/kg/hr IV to lower serum
glucose. Insulin should decrease plasma glucose at a rate of 50-75mg/dL/hr. Once plasma
glucose reaches 200mg/dL, decrease insulin infusion to 0.5 to 0.1units/kg/hr. Pt should be given
potassium to prevent hypokalemia, cardiac complications, and respiratory muscle weakness
with a dose of 20-30mEq/L when K is between 3.3-5.3 mEq/L and maintained between 45mEq/L. Pt does not need bicarbonate therapy due to pH >7.0. DKA resolves when plasma
glucose is <200mg/dL, anion gap ≤12mEq/L, and venous pH >7.3
Plan:
- Initiate 1L 0.9%NaCl IV for the first hour, then infuse 0.45% NaCl at 300mL/hr IV.
o Once glucose is 200mg/dL, change infusion to 5% dextrose with 0.45%NaCl at
150mL/hr.
- Initiate 6 units of regular insulin bolus IV followed by an infusion of 6 units/hr regular insulin
IV.
o Once glucose is 200mg/dL, change infusion to 3 units/hr regular insulin IV
- Initiate 20mEq potassium in each liter of IV fluid.
o Maintain serum potassium 4-5mEq/L
- Monitor blood glucose every hour until glucose is 200mg/dL
o Monitor blood glucose, electrolytes, BUN, venous pH, creatinine, anion gap, venous
pH, and bicarbonate every 2-4 hours until stable
- Initiate NovoLog 100 U/mL insulin pump subcutaneously 1-2 hours before discontinuation
of IV insulin at DKA resolution (blood glucose <200mg/dL, anion gap ≤12mEq/L, and venous
pH >7.3)
o Restart pump at previous setting and follow up with endocrinologist within 1 week.
- Educate patient on s/sx and prevention of diabetic ketoacidosis
o Blood glucose >250mg/dL, ketones in urine, increased thirst, fatigue, and urination,
fruity breath odor, deep and difficult breathing
o Test for ketones when blood glucose >300mg/dL with ketone test strips.
- Educate patient on diabetes management
o Importance of insulin dosing diet, exercise, SMBG
- Educate to have back up pens and needles on hand in case of pump failure in the future
- Recommend influenza, hepatitis B, and HPV vaccination.
Andrew Jung, Intern Pharmacist (777) 777-7777