Question 15. What is the single major precipitating factor for this patient’s ketoacidosis?
The single major precipitating factor for this patient’s ketoacidosis maybe due to possible infection (Harvard Health Publishing, 2019). Her WBCs are slightly elevated, and she reports mild diarrhea for the past 36 hours with some possible ill contacts from her school. On the other hand, the patient is newly diagnosed with Type I diabetes, and adhering to a new treatment regimen for this condition can be quite overwhelming for any patient (Harvard Health Publishing, 2019). Therefore, another possibility is that she missed an insulin dose earlier in the day, or she is not doing a good job adhering to a proper diet to keep the diabetes under control. In this case, the idea that a possible infection is precipitating the DKA in this patient seems quite probable. During an infection, the body requires more insulin to produce more energy to fight the infection, so in a person who is unable to produce their own insulin, this will trigger a hyperglycemic state in the body when it is under stress (Harvard Health Publishing, 2019). Then, when a person does not have sufficient insulin to signal to the cells to utilize the glucose in the blood for energy, the body thinks it has no glucose to fuel the cells energy, so the body begins to break down fat to create ketones which a more acidic state within the body (Harvard Health Publishing, 2019).
Harvard Health Publishing. (2019). Diabetic Ketoacidosis. Harvard Health. https://www.health.harvard.edu/a_to_z/diabetic-ketoacidosis-a-to-z.
Question 17. Does she need IV sodium bicarbonate to correct her acidosis, and if so, why would we give it to this patient with these labs?
Based on the labs and history presented, this patient is in diabetic ketoacidosis, which creates an acid-base imbalance of metabolic acidosis. Due to being dehydrated caused by excessive vomiting, which is a side effect of having an elevated glucose of 554, the patient could benefit from isotonic fluids. Isotonic fluids containing electrolytes and glucose are given orally, intravenously (i.e., 0.9% saline solution or 5% dextrose in 0.225% saline solution), or, in some cases, subcutaneously (Huether, 2019). Since the patient has elevated glucose, 0.9% saline should be used intravenously due to the need for rapid infusion. The 0.9% saline will be the diluting solution of the bicarbonate drip needed to correct the patient's metabolic acidosis. The patient will benefit from an intravenous bicarbonate drip due to labs showing HCO3 of 15 meq/L, an arterial blood gas pH of 7.23, and the PaCO2 of 20 mmHg. The fact that the pH is reading in the acidotic side, but the CO2 is low proves the patient is in metabolic acidosis. Buffers can absorb excessive H+ (acid) or hydroxyl ion (OH-) (base) to minimize fluctuations in pH (Huether, 2019). Buffering by bicarbonate lowers the serum value of hydrogen ions and increases the pH (Huether, 2019).
Bicarbonate administration is not recommended except for treatment of life‐threatening hyperkalemia (Wolfdorf et al., 2014). In this scenario, the patient has a potassium of 6.1 meq/L, which is elevated and could qualify for bicarbonate administration. If bicarbonate is considered necessary, cautiously give 1–2 mmol/kg over 60 min (Wolfdorf et al., 2014).
References
Huether, S. E. (2019). The Cellular Environment: Fluids and Electrolytes, Acids, and Bases. In K. L. McCance & S. E. Huether (Eds.), Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed., pp. 104-132). Elsevier.
Wolfsdorf, J. I., Allgrove, J., Craig, M. E., Edge, J., Glaser, N., Jain, V., Lee, W. W., Mungai, L. N., Rosenbloom, A. L., Sperling, M. A., & Hanas, R. (2014). Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes, 15, 154–179. https://doi-org.manowar.tamucc.edu/10.1111/pedi.12165
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