A 31-year-old man with diabetes comes to the emergency department with abdominal discomfort, nausea, and vomiting. He has not felt well for the past 2 days and has had intractable vomiting. The patient stopped taking his regular dose of insulin as he was unable to "hold anything down." His initial laboratory results are positive for serum ketones and show blood glucose of 360 mg/dL. In the emergency department, he is started on intravenous normal saline with potassium and a continuous insulin infusion. Five hours after his admission to the intensive care unit, he feels better. Laboratory results are as follows:
Ten hours after admission, the patient feels better. He has had no vomiting over the last several hours and his abdominal discomfort has subsided. He is tolerating oral fluid. The patient is currently on an insulin infusion and intravenous fluids. Repeat laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 31-year-old man with diabetes comes to the emergency department with abdominal discomfort, nausea, and vomiting.  He has not felt well for the past 2 days and has had intractable vomiting.  The patient stopped taking his regular dose of insulin as he was unable to "hold anything down."  His initial laboratory results are positive for serum ketones and show blood glucose of 360 mg/dL.  In the emergency department, he is started on intravenous normal saline with potassium and a continuous insulin infusion.  Five hours after his admission to the intensive care unit, he feels better.  Laboratory results are as follows:
 Ten hours after admission, the patient feels better.  He has had no vomiting over the last several hours and his abdominal discomfort has subsided.  He is tolerating oral fluid.  The patient is currently on an insulin infusion and intravenous fluids.  Repeat laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beb8_1c7d_8f63_6d96da5613af_MD0005_00 Patients with diabetic ketoacidosis (DKA) can be transitioned to subcutaneous (SQ) insulin once the ketoacidosis has resolved, provided they are reliably able to eat. Criteria for transition from intravenous (IV) to SQ insulin include glucose <200 mg/dL along with 2 of the following: serum anion gap <12 mEq/L, serum bicarbonate >15 mEq/L, and venous pH >7.30. This patient's anion gap is 8 (138 - (112 + 18) = 138 - 130 = 8), and his serum glucose and bicarbonate have improved to acceptable values. The patient should now be started on SQ insulin. He should be managed with a combination of long-acting insulin (basal insulin [eg, glargine, detemir]), rapid-acting insulin (bolus insulin [eg, regular, aspart, lispro]) with meals, and correction insulin for hyperglycemia on a sliding scale. However, there is a slight delay in absorption of insulin when it is given subcutaneously. It is recommended that the IV insulin infusion be continued for about 1-2 hours after SQ insulin is started to give the SQ insulin time to take effect and prevent rebound ketoacidosis (Choices D and E). (Choice A) This patient's bicarbonate level has improved to an acceptable level. Administration of bicarbonate is considered only in patients with severe acidosis (eg, pH <6.9), which can result in decreased cardiac contractility and systemic vasodilation. (Choice C) The insulin infusion does not need to be tapered, but it should not be discontinued until SQ insulin has been given. Educational objective: Intravenous (IV) insulin for diabetic ketoacidosis should be continued until serum glucose is <200 mg/dL, the anion gap is <12 mEq/L, serum bicarbonate is >15 mEq/L, and the patient is able to eat. Subcutaneous insulin can then be started, but the IV insulin should be continued for 1-2 hours to prevent rebound ketoacidosis. References: Diabetic ketoacidosis. (http://www.ncbi.nlm.nih.gov/pubmed/15887449)

A 31-Year-Old Man with Diabetes Comes to the Emergency Department