Advanced Pharmacy Fun

[ultracet]

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I thought i'd throw out another case.


A 24 YO patient with type 1 DM is brought to the ED in a semi-comatose state. The patient's abdomen is firm, with some complaints of pain and nausea. BP is 105/65, though her BP dropped to 85/50 when sitting up 20 mins ago. Her insulin dose is lispro 6 units/ 6 units/ 8 units with meals and NPH at bedtime 20 units.

Her admission lab results reveal:

Blood Glucose: 698 mg/dL
Potassium: 4.9 mEq/L
Sodium: 147 mEq/L
Chloride: 105 mEq/L
Bicarb: 9 mEq/L
Serum Cr: 2.1 mg/dL
Hemoglobin: 15.4 gm/dL
Hematocrit: 48%
Serum ketones: moderate
Uninalysis:
SpGr: 1.030
pH: 5.5
glucose: 4+
ketones: 4+




A) identify condition
B) recommend treatment including fluids, meds, electrolytes, and monitoring



If you need to know any abrev. please let me know. If you need any more info just ask though i think there is enough there.
Oh and don't make it harder than it is.

 

[luckyPharmD.stu]

i'm going to take a guess for fun...i'm guessing the patient has diabetes.

 

[Caverject]

i'm going to take a guess for fun...i'm guessing the patient has diabetes.

yeah...what gave you the clue it's diabetes? The intro that states they have type 1 diabetes?

Did you get that case out of Dipiro's case book? I worked that exact case last week during recitation.

 

[luckyPharmD.stu]

honestly, i didn't know what dm stands for...yeah, call me an idiot; i deserve it. the real reason of how i knew that was because the blood glucose level was way too high, so i guessed it was diabetes.

 

[ultracet]

lol

no it was off of a test

you've got to be kidding me?!? there was a book with my test questions in it....

i'm really thinking a lot of explitives right now......... 😡


and i find out now....

we searched all year for a book with the questions in it....
😡

 

[ultracet]

what is everyone studying right now? tests coming up? just post and i'll dig out some questions for you

 

[WilkesRx]

DKA, and recommended insulin drip. Not really sure what else, i remember having that case last year at some point.

 

[Trancelucent1]

I would guess DKA as well, not quite sure what fluids to give though. Ask me at the end of the year and I should know 🙂

 

[psychoandy]

I would guess DKA as well, not quite sure what fluids to give though. Ask me at the end of the year and I should know 🙂

Since you got the diagnosis, I'll guess sodium bicarb in NS with added electrolytes such as KCl. Sodium bicarb because the serum bicarb is ridiculously low and you need to make the body more basic since you're in acidosis.

I have no idea of what drugs to use, but I do know that this dude needs to get that glucose out of his blood stat (insulin drip?), and that his nephrons aren't working all that well.

 

[Caverject]

Since you got the diagnosis, I'll guess sodium bicarb in NS with added electrolytes such as KCl. Sodium bicarb because the serum bicarb is ridiculously low and you need to make the body more basic since you're in acidosis.

I have no idea of what drugs to use, but I do know that this dude needs to get that glucose out of his blood stat (insulin drip?), and that his nephrons aren't working all that well.

Uh...no you do not use Sodium Bicarb. It is not first line for DKA. Once you start giving fluids (NS) the body will start balancing out. If at that point, it doesn't work, then you do bicarb, but it's reserved for last line.

 

[psychoandy]

Uh...no you do not use Sodium Bicarb. It is not first line for DKA. Once you start giving fluids (NS) the body will start balancing out. If at that point, it doesn't work, then you do bicarb, but it's reserved for last line.

That's why it was a guess, and why I don't have RPh at the end of my name.

 

[TotalKayOs]

would NS be the right choice seeing as to how high the Na is. possibly free water bolus with lasix to get the kidneys working and insulin drip. also when was the last time this person ate? he is def dehydrated. def use K supplement since the insulin is going to cause a shift in K into the cells and during acidosis the K becomes falsely elevated. the person's K is prob much much lower than the lab would indicate.

 

[kristakoch]

Yes, fist line is a NS boluses and a insulin drip titrated to drop glucose levels at about 75 mg/dL/hr (no faster). After a few hours of tx, then K is replaced. Na Bicarb is reserved very last line for this.
ALso, don't forget to start up a D5W drip after the gucose drops to the 200s range to start replacing the body's glucose and to prevent hypoglycemia.

Yes- gen med rotation did pay off (and peds too )🙂

 

[GravyRPH]

free water bolus

Would that be like starting a line of Sterile Water for Injection at 75mls/hr?

 

[bananaface]

Would that be like starting a line of Sterile Water for Injection at 75mls/hr?

Aren't you only able to put in SW by a central line at a very slow rate so that it doesn't result in the local cells being hypertonic, taking in excessive water, and bursting? The hospital I used to work at had a policy against ever using plain SW, as they were afraid of lawsuits from it being done at too fast of a rate, or placed somewhere besides the central line. Or, so I hear.

 

[TotalKayOs]

as far as know SW should never be used, a free water bolus is basicallt D5W.

 

[GravyRPH]

Aren't you only able to put in SW by a central line at a very slow rate so that it doesn't result in the local cells being hypertonic, taking in excessive water, and bursting? The hospital I used to work at had a policy against ever using plain SW, as they were afraid of lawsuits from it being done at too fast of a rate, or placed somewhere besides the central line. Or, so I hear.

It was a trick question. 😀 Be careful when you say things like "free water bolus"

http://www.ismp.org/MSAarticles/water.htm