CASE STUDY, PRISTINA, 1994

The unconscious female patient , 22 years old , has been transferred to the Department of Endocrinology after the urgent appendectomy had been performed on the Abdominal Surgery Department, Surgical Clinic, CHC Pristina. She has been urgently admitted to the Abdominal Surgery department having signs and symptoms and signs of acute abdomen. The patient is known type 1 diabetic hospitalized and treated several times in last 5 years at the Department of Endocrinology at the Clinic for Internal Diseases CHC Pristina.

The patient started complaining about malaise, frequent urination and fever two days prior to admission to Surgery. At the evening first day she begun feeling nausea and during the morning next day she felt pain in the middle and lower parts of abdomens that have been increasing gradually, becoming very strong in the evening and she became prostrate and highly febrile.

The patient and her family then decided to go to the doctor in Pec, where she lived. During  the examination, a doctor find strong resistance of the anterior abdominal wall on palpation and after registering leukocytosis (16000/ml) transported the patient by ambulance to Pristina.

DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMEN CAN BE FOUND ON:

ENGLISH\CASE 2 WORKUP\Acute abdomen.xps

An urgent appendectomy was performed. The blood sugar was high (16.7 mmol/l) and the patient had to receive 250ml 0.9% NaCl + regular insulin 16 j prior to surgery . She also had 2x 500ml 0.9%NaCl during the operation, and after that 500ml of 10% glucose solution + 16 j of regular insulin. The blood glucose after the appendectomy was 7.1 mmol/l. During the first day after surgery in the ED blood glucose levels were 7-10 mmol/l, and the patient received s.c. 6h – period subcutaneous regular insulin doses matching the actual glucose level. However, although the anesthesia effect passed she was lethargic and confused.

No macroscopic signs of appedincitis were seen during surgery and no in-situ signs of other abdominal diseases were registered. The appendix tissue was sent to pathologic analysis.

On the 2nd day in ED, blood glucose continued rising despite subcutaneous insulin and fluids. On the third day, the patient was transferred to the department of endocrinology for further treatment.

On the admission, patient is in stupor, with the reaction (flection) to stronger physical irritation (pinching, stretching).  She does not react to loud calls but open her eyes slightly during the physical irritation, and is unable to formulate words but only moans during the loud calling and in response to pain.

TASK 1: ASSESS CONSCIOUSNESS IMPAIRMENT USING GLASGOW COMA SCALE

Glasgow Coma Scale is provided at http://www.mdcalc.com/glasgow-coma-scale-score/

 

She is febrile (38.7C), breathing deeply with the respiratory rate of about 23-25/min (Kussmaul type). A faint acetone smell is felt in the scent. She is lean,  BMI 20.66 kg/m2 (body weight 59 kg, height 1.69m) with no visible deformities.  Skin is pale and dry and mucous membranes are very dry with no visible cyanosis.

The skull is normally shaped with no visible deformities.  The face is symmetric, including eyelids, the eyes are sunken, conjunctiva and sclera are normally colored but dry, the pupils react to light symmetrically, but somewhat sluggish.  Ears and nose are symmetric, nostrils movements are normal and the canals are not obstructed. The oral mucous membranes are dry, the color is normal, upper surface of the tongue is white and coated. The neck is cylindrical, with no visible deformities. No palpable lymph nodes on neck were noticed. There is no visible thyroid enlargement, the consistency during palpation is normal. Thyroid is moving freely during swallowing. The carotid pulsations are normal, carotid pulse rate is 100/min, but jugular venous pulse pressure is decreased (hardly palpable).

The chest wall is cylindrical with no visible deformities. Respiratory movements are normal, including the intercostal spaces and mobility.  Percussion sounds are normal. Respiratory auscultation reveals normal breathing sounds.

The heart frequency rate is 100/min, no rhythm disturbances were registered.  Heart sounds are normal, no pathologic murmurs. TA=90/60 mmHg.

The abdomen is lean with diffuse resistance and tenderness to palpation. Liver span 7 cm in right mid-clavicular line; edge normal, palpable 1 cm above right costal margin. Bowel sounds are active. Spleen not palpable. There is postoperative properly dressed wound on the right lower abdominal quadrant.  No costo-vertebral angle tenderness is noted.  External genitalia show no lesions.

Extremities are cold and without edema. Meningeal signs negative.  Flexion movements in response to pain are symmetrical. Passive resistance to movements is bilaterally normal. No involuntary movements were recognized. No varicosities, stasis pigmentation or ulcers on the lower extremities were registered. Arterial pulses on lower extremities decreased.

TASK 2: CONSIDER THE CAUSES OF DIABETIC KETOACIDOSIS USING:

http://www.mayoclinic.com/health/diabeticketoacidosis/DS00674/DSECTION=causes

Fingertip stick measurement on admission revealed high blood glucose levels > 25 mmol/l

ECG on admission:

 

 

 

 

 

 

 

RTG on admission:

 Abdominal ultrasound

Abdominal ultrasound:  liver normal – 13.5 cm.  Portal vein 1.1 cm.  gallbladder 2.0 cm, gallbladder wall 1.8mm. Spleen 12cm. Pancreas could not be seen. Kidneys bilaterally enlarged (15 and 15.5cm, respectively) with mildly enlarged pyelocaliceal structures. Urinary bladderappears normal.

 

Laboratory findings on admission:

ENGLISH\CASE 2 WORKUP\Case2 HEMATOLOGIC ANALYSIS 1h.htm

..\CASE 2 WORKUP\Case2 Biochemical.htm

ENGLISH\CASE 2 WORKUP\Case2 Biochemical.htm

The referent values of common biochemistry analyses can be found on

ENGLISH\CASE 2 WORKUP\Case2 URINARY.htm

TASK 3: ASSESS URINE OUTPUT ml/kg/hour

ENGLISH\CASE 2 WORKUP\CASE2 ACIDBASE 1h.htm

ENGLISH\CASE 2 WORKUP\CASE2 Serum lactate and ketones.htm

The interpretation of the serum lactate values can be found on:

http://emedicine.medscape.com/article/768159-overview

The interpretation of the serum ketone values can be found on:

http://type1diabetes.about.com/od/technologyandequipment/p/How-To-Read-Blood-Ketone-Test-Results.htm

http://emedicine.medscape.com/article/2087381-overview

 

TASK 4: MAKE ASSESSMENT OF ACID-BASE STATUS USING http://harrisons.unboundmedicine.com/harrisons/ub/view/Harrisons-Manual-of-Medicine/148736/all/acid_base_disorders

ENGLISH\CASE 2 WORKUP\Case2 ELECTROLYTES 1h.htm

TASK 5: CALCULATE SERUM OSMOLALITY USING:

2Na (mmol/l) + serum glucose (mmol/l) + urea (mmol/l)

Prior to that, correct serum sodium using

measured Na+  + 0.3 (glucose - 5.5) mmol/

TASK: CALCULATE ANION GAP USING

Anion Gap = Na - (Cl + HCO3-)

TASK 6: MAKE ASSESSMENT OF SEVERITY OF DKA USING

ABLE 2
Diagnostic Criteria for Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Mild DKA

Moderate DKA

Severe DKA

HHS

Plasma glucose (mg per dL [mmol per L])

> 250 (13.9)

> 250

> 250

> 600 (33.3)

Arterial pH

7.25 to 7.30

7.00 to 7.24

< 7.00

> 7.30

Serum bicarbonate (mEq per L)

15 to 18

10 to < 15

< 10

> 15

Urine ketones

Positive

Positive

Positive

Small

Serum ketones

Positive

Positive

Positive

Small

Beta-hydroxybutyrate

High

High

High

Normal or elevated20

Effective serum osmolality (mOsm per kg)*

Variable

Variable

Variable

> 320

Anion gap†

> 10

> 12

> 12

Variable

Alteration in sensoria or mental obtundation

Alert

Alert/drowsy

Stupor/coma

Stupor/coma

DKA = diabetic ketoacidosis; HHS = hyperosmolar hyperglycemic state.

*—Effective serum osmolality = 2 × measured Na (mEq per L) + (glucose [mg per dL] ÷ 18).

†—Anion gap = Na+ – (Cl– + HCO3– [mEq per L]).

Adapted with permission from Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Hyperglycemic crises in diabetes. Diabetes Care 2004;27(suppl 1):S95, with additional information from reference 20.

 

TASK 7: DOES THE PATIENT NEEDS INTRODUCTION OF CENTRAL VENOUS LINE

The criteria for installation of CVK are listed here:

ENGLISH\CASE 2 WORKUP\Case1 CRITERIA CVC.htm

TASK: CALCULATE ANION GAP USING

Anion Gap = Na - (Cl + HCO3-)

TASK 8: CONFIRM THE INITIAL DIAGNOSIS OF THE CONDITION  USING:                                                 

ENGLISH\CASE 2 WORKUP\Case1 HHSvsDKA.htm

TASK 9: CALCULATE TOTAL BODY WATER DEFICIT USING

TBW deficit (L) = ( 0.6 * Wt * [(Na/140) - 1] )

 

DIABETIC KETOACIDOSIS MANAGEMENT HIGHLIGHTS

Fluid resuscitation

Start 0.9% NaCl at 15–20 mL/kg/hr for first hr (add colloid if

hypovolemic shock), then

If Na+ is normal or high, give 0.45% NaCl at 4–14 mL/kg/hr

If Na+ is low, give 0.9% NaCl at 4–14 mL/kg/hr

Add dextrose when glucose is < 250 mg/dL

Goal is to correct total body water deficit in the first 24 hr

Insulin therapy

0.1 U/kg bolus followed by continuous infusion at 0.1 U/kg/hr

Goal is to decrease glucose by 50–75 mg/dL/hr

Continue insulin until pH, bicarbonate, and anion gap normalize

Overlap IV insulin with subcutaneous insulin for 1–2 hr after resolution

of DKA

Electrolyte repletion

Add 20–30 mEq potassium to each liter of IV fluid if potassium is

< 5.3 mEq/L

Replace phosphate if phosphate is < 1 mg/dL

Give bicarbonate if pH is < 7.0

 

DKA = diabetic ketoacidosis; IV = intravenous.

TASK 10: PLAN FLUID RESUSCITATION FOR THE FIRST 6 AND 6-12H.

TASK 11 : PLAN POTASSIUM SUBSTITUTION FOR FIRST 4 HOURS

TASK 12 : TITRATE I.V. INSULIN DOSE PER HOUR USING IV INFUSION PUMP OR VIA COUNTING DROPS/MIN USING FOLLOWING PROTOCOL FOR DIABETIC KETOACIDOSIS.

ENGLISH\CASE 2 WORKUP\Case2 INSULIN.htm

First hour after the initiation of the therapy

Glucose  23.2 MMOL/L

Urine output 60 ml

Ta 90/60 mmHg

Second hour

Glucose 21.5 mmol/l

Na++ 143 mmol/l

K+  4.0

P—1.4

Mg++ 1.6

TA 95/60 mmHg

Urine output 75 ml 

TASK 13: PLAN THERAPY FOR THE NEXT HOUR. 

 

Third hour

Glucose 20.0 mmol/l

Na+ 142 mmol/l

K+ 3,6 mmol/l

Urine output 80 ml

pH 7.15

PCO2 32

PO2 87

SO2 98%

Serum bicarbonates 14 mmol/l

Serum lactate 2.2 mmol/l

Blood ketones 4.9 mmol/l

3-OH butyrate 3.0 mmol/l

TA 95/70 mmHg

 

TASK 14: PLAN THERAPY FOR THE NEXT HOUR

 

Fourth hour

Glucose 17.1

Na+139

K+ 3.95

Urea 9.2

Creatinine 109

Urine output 85ml

TA 100/65 mmHg

TASK 15: PLAN THERAPY FOR THE NEXT HOUR

 

Fifth hour

Glucose 15.0 mol/l

Urine output 85 ml

TASK 16: PLAN THERAPY FOR THE NEXT HOUR

Sixth hour

Glucose 13.7 mmol/l

Na+ 139 mmol/l

K+ 4.0

pH 7.18

PO2 87

PCO2 33

SO2 98

Serum bicarbonates 16 mmol/l

Urine output 90ml

TA 100/70 mmHg

TASK 17: PLAN THERAPY FOR THE NEXT HOUR

 

Seventh hour

Glucose 12.1 mmol/l

Urine output 90 ml

TA 110/70 mmHg

TASK 18: PLAN THERAPY FOR THE NEXT HOUR

Eight hour

Na+ 140

K+ 4.1

pH 7.14

PO2 38

PCO2 33

SO2 97

Serum bicarbonates 16 mmol/l

Serum lactate 1.2 mmol/l

Blood ketones 4.6 mmol/l

3-OH butyrate 2.8 mmol/l

TA 110/70 mmHg

TASK 19: Despite the good progression in TBW resuscitation, a fall in serum osmolality, improvement in serum electrolyte levels the fall in serum ketones, and especially acid base parameters did not correct as expected. During the 6th hour of therapy the patient became alert, but still drowsy and ate one banana. However during the eight hour she became lethargic/stuporous again.  What would you do?

 

Ninth hour

Glucose 11.2

Urine output 100 ml

TA 115/80 mmHg

 The patient suddenly died during the ninth hour. The exact moment of death was not noted. The reanimation was unsuccessful. The exact cause of sudden death was not detected, since the family refused authopsy.

TASK 20: Consider the possible causes of the sudden death