Emergent abdominal surgery on pt with nonketotic hyperglycemia

[excalibur]

How would you manage the following patieint in the OR?

51 y/o 70 kg AAF with PMH significant for CAD (s/p CABG 3 years ago), PVD (s/p Left Iliac Stent), NIDDM, HTN, and HPLD presents to ER from OSH with hyperglycemia, altered mental status, and abdominal pain. The patient experienced a one week history of diarrhea and one day h/o altered mental status before presenting to OSH. At OSH, her blood glc was 800, urine ketones negative, ph 7.4 and bicarb of 20. At OSH, pt was given a liter bolus of NS, 20 units of SC insulin and started on an insulin gtt. Pt immediately transferred to your ER for evaluation. VS upon arrival to ED—P 100, BP 79/39, R 24, SpO2 98% on 4L NC. Pt is disoriented, has dry mucous membranes, severe abdominal tenderness upon palpation, and gross melena. The ED staff have placed a Right femoral CVL and have resuscitated her with a total of 3 liters of NS. The ED has also started a norepinephrine infusion, which was dc'd after an hour when her BP was 150/53. EKG shows NSR. Labs: H/H 10/29, Coags 16.3/1.3/24.1 BMP: Na 126, K 3.9, Cl 88, CO2 20, BUN 163, Cr 6.5, Glc 410, Ca 8.4 Osmolality is increased at 349. Serum ketone neg. ABG: 7.312/39.2/100/19.9/BE -6. Insulin drip is being continued from OSH and is running at 5 units/hr. CT abd/pelvis reveals pneumatosis in the rectum and sigmoid colon. Surgery has been consulted and they wish to take pt emergently to the OR for ex-lap with possible colon resection for ischemic bowel.

Preop optimization?
Monitors? Lines?
Induction?
Fluids? Drips?
Intraoperative monitoring?
Pain control?

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[excalibur]

Don't forget the Oil of Wintergreen on your mask!

OH YES! It was quite foul. Worst smell as an anesthesia resident so far.

 

[Planktonmd]

Go to the OR, induce GA gently, intubate, give a boat load of fluids.
An A line is a good idea.
Keep an eye on the urine output.
Let the surgeons do what they need to do.
He might live if you keep it simple.

 

[excalibur]

are you just going to give NS?

or are you going to give NS with 20 mEq KCl while giving that insulin drip given his K is like 3.3.

Also, how often are you monitoring glc, and would you ever switch to D5NS once the glc gets to around 200?

 

[dhb]

How would you manage the following patieint in the OR?

51 y/o 70 kg AAF with PMH significant for CAD (s/p CABG 3 years ago), PVD (s/p Left Iliac Stent), NIDDM, HTN, and HPLD presents to ER from OSH with hyperglycemia, altered mental status, and abdominal pain. The patient experienced a one week history of diarrhea and one day h/o altered mental status before presenting to OSH. At OSH, her blood glc was 800, urine ketones negative, ph 7.4 and bicarb of 20. At OSH, pt was given a liter bolus of NS, 20 units of SC insulin and started on an insulin gtt. Pt immediately transferred to your ER for evaluation. VS upon arrival to ED—P 100, BP 79/39, R 24, SpO2 98% on 4L NC. Pt is disoriented, has dry mucous membranes, severe abdominal tenderness upon palpation, and gross melena. The ED staff have placed a Right femoral CVL and have resuscitated her with a total of 3 liters of NS. The ED has also started a norepinephrine infusion, which was dc’d after an hour when her BP was 150/53. EKG shows NSR. Labs: H/H 10/29, Coags 16.3/1.3/24.1 BMP: Na 126, K 3.9, Cl 88, CO2 20, BUN 163, Cr 6.5, Glc 410, Ca 8.4 Osmolality is increased at 349. Serum ketone neg. ABG: 7.312/39.2/100/19.9/BE -6. Insulin drip is being continued from OSH and is running at 5 units/hr. CT abd/pelvis reveals pneumatosis in the rectum and sigmoid colon. Surgery has been consulted and they wish to take pt emergently to the OR for ex-lap with possible colon resection for ischemic bowel.

Preop optimization?
Monitors? Lines?
Induction?
Fluids? Drips?
Intraoperative monitoring?
Pain control?

Delay case HbA1c must be outta wack

ARF, CAD & ischemic bowel... the dudette is toast keep it simple: fluids insuline and norepi if needed.

 

[Planktonmd]

are you just going to give NS?

or are you going to give NS with 20 mEq KCl while giving that insulin drip given his K is like 3.3.

Also, how often are you monitoring glc, and would you ever switch to D5NS once the glc gets to around 200?

Send a blood gas whenever you have nothing else to do, otherwise give NS or LR and try to improve the hemodynamic situation and the urine output.
Compensate for the metabolic acidosis with some hyperventilation.
This patient is septic and probably has dead bowel so your main job is volume resuscitation.
Don't worry too much about hypokalemia caused by Insulin.
That 20meq potassium in NS is something internists do on the floor we do things a little differently.

 

[Licoricestick]

Don't worry too much about hypokalemia caused by Insulin.
That 20meq potassium in NS is something internists do on the floor we do things a little differently.

I probably would give some K cause if you keep running that insulin infusion and you may end up with a K of 2.5 which I'm not so keen on. However, I wouldn't give much because of the renal failure. Although you could just scoop the K out of the cells with a little sux

I'm having trouble figuring out what units the results are in - esp BUN (which I assume is what I'd call Urea), creatinine and glucose - bit of help anyone? Can't convert to what I know until I know what the orginial units are!

 

[excalibur]

I probably would give some K cause if you keep running that insulin infusion and you may end up with a K of 2.5 which I'm not so keen on. However, I wouldn't give much because of the renal failure. Although you could just scoop the K out of the cells with a little sux

I'm having trouble figuring out what units the results are in - esp BUN (which I assume is what I'd call Urea), creatinine and glucose - bit of help anyone? Can't convert to what I know until I know what the orginial units are!

BUN and Cr are mg/dL

 

[Licoricestick]

BUN and Cr are mg/dL

Thanks!
Glucose units anyone?

And I take back my comment about probably giving K - with renal function like that I'd go with frequent ABGs and only give K if it started to drop further.

 

[psychbender]

Thanks!
Glucose units anyone?

And I take back my comment about probably giving K - with renal function like that I'd go with frequent ABGs and only give K if it started to drop further.

Glucose same units, mg/dL