Case Study: Hyperglycemia, concern for diabetic ketoacidosis, and type 1 diabetes
The patient presented to the emergency room with hyperglycemia and possible diabetic ketoacidosis after not taking his insulin for 3 days.
In the emergency room, the patient's lab work was obtained, and he was determined to not have diabetic ketoacidosis. He was provided with a correction dose of insulin for a glucose value of 385 mg/dL. With the noted imbalance in his pre-admission basal and bolus insulin doses, a weight-based calculation was used to determine a dose of insulin glargine. The patient is 91 kg, and therefore, 18 units of insulin glargine were administered. The patient was then admitted to the hospital for further observation.
After admission to the hospital, he was prescribed a general diet, with 3 meals provided per day. Meal doses of insulin aspart were added to his regimen, along with correction doses of insulin aspart. His hyperglycemia resolved, and a discussion regarding hospital discharge began.
A social worker was an invaluable asset when assisting this patient with discharge planning and was able to contact the patient's sister. After a family meeting, the patient was hopeful to be able to stay with his sister, as well as eat and manage his diabetes more regularly. The social worker assisted in helping the patient obtain medical assistance so that he could obtain a supply of insulin, syringes, and glucose testing supplies. Prescriptions for all diabetes-related medications and supplies were provided, and a pharmacy was contacted to ensure that these would be provided to him with his medical assistance. The social worker also provided a list of community resources for the patient to obtain medical care for diabetes follow-up, as well as for his psychiatric illness.
When trying to establish a basal insulin dose for a patient with type 1 diabetes, it can be helpful to start with a weight-based calculation of 0.2 units/kg/day.
When examining a patient's total daily insulin requirements, it is helpful to consider that basal insulin doses are about 50% of the total daily insulin requirements, and bolus insulin doses account for the other 50% of the total daily insulin requirements. This is not exact, but it can be helpful to consider if a patient's basal insulin might be covering oral intake.
When trying to determine if a patient is in diabetic ketoacidosis, it is important to examine the beta-hydroxybutyrate level. Beta-hydroxybutyrate is the main metabolic product in ketoacidosis. Levels correlate better with changes in arterial pH and blood bicarbonate levels than ketones.
Laboratory values that are indicative of diabetic ketoacidosis include the following:
- Glucose: >250 mg/dL
- Anion Gap: >12 mEq/L
- pH: <7.3
- Bicarbonate: <18 mEq/L
- Beta-hydroxybutyrate: >3.8 mmol/L
Jennifer A. Grenell, APRN, CNP, practices at the Mayo Clinic department of endocrinology, specializing in diabetes management.