I'm a new ICU nurse, I've been on this unit for about 4 months. Last night I received an admission which kinda confused me.
Here's the info: (adjusted to protect his privacy)
28 y/o male, type 1 diabetic diagnosed as a child. N/V for about a week. When he arrived in the ER his blood sugar was 170-ish. Na 142, CO2 <10, Chloride 111, H+H wnl, but on the high end, Anion gap 21, elevated WBC, pH on ABG was 7.0, acetone level was high.
Diagnosis was dehydration from the n/v and he was given 4L NS over about 3-4 hours. Checked another accucheck and his sugar was 350's. Orders were received for admission to the ICU and DKA protocol. He was started on an insulin gtt @ 9 units per hour, based on the weight based calculation built in to the protocol. 2 hours later, still in the ER, his sugar was 64. Anion gap was still 20. ER nurse turned off the insulin gtt and called the doc who didn't give any additional orders. She called me report and I paged the doc who told me to check an accucheck once he gets to the ICU and call him with the results. Upon admission to my unit, his sugar was 120. I received orders for D5 1/2NS @ 200, 1 amp D50, restart the insulin gtt @ 1 unit/ hr, check an accucheck in 1 hour, call with results. Needless to say, 1 hour later his blood sugar was nearly 400. The doc proceeded to ignore the titration formula on the protocol for the next 5 hours (during which time I charted my ass off, cya) until his accuchecks were back down to about 175. (once his sugars were down I managed to convince the doc to use the protocol for future titration) By the time I left his gap had decreased to 17 and pH on VBG was 7.24, acetone level was still positive.
My question is this: should we have been using the DKA protocol to correct this acidosis or is there another way to fix this? Obviously it was working, but it seemed as though we were putting him into DKA in order to correct the A portion of DKA...
Help! I'm confused!
Sep 25, '11
Sounds like starvation ketoacidosis. Poor intake for > 3 days, high gap, positive ketones, but normal blood glucose. I've personally never seen a DKA patient come in with an initial normal glucose. I have however seen starvation ketoacidosis where blood sugars were almost a non-issue and you were just cranking in fluids, D5 or D5/.45 later on for a glucose source and intracellular hydration.
You really didn't need the DKA protocol. You're going to give fluids and the pH would normalize itself over time, you didn't need to be mixing bicarb into the fluids or anything insane like that.
Last edit by detroitdano on Sep 25, '11