Originally Posted by poppy07
I thought this was a fairly interesting patient... young lady comes in with DKA and chest pain. Her glucose in the 300's, put on NS and received nitro paste % continuous rate insulin drip, while in E.D., arrived to unit: then bolus of 1 liter 1/2 NS with Bicarb, then 1/2 NS, then D51/2 NS. She eventually complained of a headache...medicated with Tylenol...her neuro status was quite consistent, AA&0x4. after medicating, pt rests (came in very early a.m.---maybe genuinely tired), or was a slight change in her mental status? was the headache from the nitro paste or from some mild cerebral edema, perhaps?
What do you think?
Poppy, the H/A was probably from nitro (like everybody else said)...BUT, your thinking wasn't way off.
When someone comes in with true DKA (like your patient) their blood is very concentrated (from the hyperglycemia, polyuria, etc.) . If you TOO RAPIDLY drop the sugar from iv-insulin bolus the blood can TOO RAPIDLY lose its osmotic gradient (it can become rapidly hypotonic) . When this happens too quickly, the fluid from the (now relatively hypotonic and dilute) blood can rush into tissues... Including brain tissue....which is where cerebral edema can occur. This phenomena(sp?) is exactly why endocrinologists (or any doctor treating it) will bring down hyperglycemia in DKA over several hours rather than over several minutes. At least this is the theory...
The rapid fluid bolus you witnessed will unlikely cause cerebral edema in these patients and is kinda par-for-the-course in DKA.
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