A 54-year-old woman is brought to the emergency department due to disorientation. She was recently on vacation and received treatment with high-dose oral prednisone for severe poison ivy dermatitis. In the emergency department, her temperature is 37 C (98.6 F), blood pressure is 138/80 mm Hg, pulse is 102/min, and respirations are 22/min. The mucous membranes are dry. Laboratory results show random blood glucose of 1020 mg/dL with a normal anion gap. Her hemoglobin A1c is 7.6%. The patient is started on intravenous fluids and an intravenous insulin infusion. After a day on intravenous insulin, her mental status is normal and she is transitioned to subcutaneous regular human insulin based on a sliding scale. Her finger stick blood glucose readings are 200-250 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old woman is brought to the emergency department due to disorientation.  She was recently on vacation and received treatment with high-dose oral prednisone for severe poison ivy dermatitis.  In the emergency department, her temperature is 37 C (98.6 F), blood pressure is 138/80 mm Hg, pulse is 102/min, and respirations are 22/min.  The mucous membranes are dry.  Laboratory results show random blood glucose of 1020 mg/dL with a normal anion gap.  Her hemoglobin A1c is 7.6%.  The patient is started on intravenous fluids and an intravenous insulin infusion.  After a day on intravenous insulin, her mental status is normal and she is transitioned to subcutaneous regular human insulin based on a sliding scale.  Her finger stick blood glucose readings are 200-250 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bec0_f62e_8f63_836eea4d1546_MD0005_00 This patient has type 2 diabetes with a hyperglycemic hyperosmolar nonketotic state (HHS), characterized by very high glucose (frequently >1000 mg/dL), mental status changes, and no associated ketoacidosis. The most common causes of HHS include infections, major illnesses, dehydration, and drugs such as corticosteroids, antipsychotics, diuretics, sympathomimetic agents, and beta blockers. Initial management of HHS includes high-flow intravenous (IV) fluids, continuous IV insulin infusion, and careful potassium replacement. Patients with HHS initially require very high doses of IV insulin due to insulin resistance induced by stress, infection, corticosteroids, and hyperglycemia. Subcutaneous insulin is generally started once the glucose has been corrected to <200 mg/dL and the patient is able to eat consistently. Short-acting human insulin or insulin analogue (lispro, aspart, or glulisine) should be given for meals as well as intermittent correctional boluses based on the level of blood glucose (sliding scale). However, short-acting insulin alone is not sufficient for glycemic control in most hospitalized patients, and basal insulin (eg, detemir, glargine) should be added as well (Choices D and E). (Choices B and C) Oral anti-diabetic agents are not typically used in hospitalized patients, particularly in those with poorly controlled diabetes. Oral medications could be considered at the time of discharge or post-hospital follow-up. Educational objective: Hyperglycemic hyperosmolar nonketotic state is characterized by severe hyperglycemia, acute mental status changes, and absence of ketoacidosis. Initial management includes intravenous fluids and continuous insulin infusion. Stabilized patients can transition to subcutaneous insulin with a basal-bolus regimen. References: Evidence-based management of hyperglycemic emergencies in diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/21978840) Hyperosmolar hyperglycemic state. (http://www.ncbi.nlm.nih.gov/pubmed/15887451)

A 54-Year-Old Woman Is Brought to the Emergency Department Due