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A 54 year old obese person come in emergency with altered consciousness level a
A 54 year old obese person come in emergency with altered consciousness level and increase respiratory rate (tachypnia) for last 4 hours.
He is having history of uncontrolled diabetes mellitus since 15 years, as he was not following any medical advice from physician. He was on insulin therapy for 3 years, but he was not taking regular dose of insulin. Patient’s relative is telling that he is also having complain of weakness and decrease urine output for last 2 days.
On General examination, physician noted
Dryness of mouth
Pale & dry conjunctive
Shrunken eye ball.
Low volume pulse
Tachypnea (increase respiratory rate)
Tachycardia (increase heart rate)
Very low blood pressure (70/40 mm Hg).
Doctor makes admission in ICU and asked immediately for blood investigation.
Laboratory Investigation
Parameter Value Reference range
RBS 500 mg/dl 140 mg/dl
Serum Acetone 10 mg/dl <1 mg/dl
Serum Creatinine 2.5 mg/dl 0.4 - 1.4 mg/dl
Blood Urea 150 mg/dl 15 - 45 mg/dl
Serum Na+ 120 mmol/l 135 - 145 mmol/l
Serum K+ 6.0 mmol/l 3.5 - 5.0 mmol/l
pH 7.35 - 7.45
pO2 95 mmHg 90 - 100 mmHg
pCO2 24 mmHg 32 - 40 mmHg
HCO3- (Bicarbonate) 12 mmol/l 24 - 32 mmol/l
Diagnosed = “Diabetic ketoacidosis with acute renal failure”
Advised to following treatment.
Inj normal saline fast I.V. (4-5 litre in 1st 24 hrs) Until systolic blood pressure reaches to normal
Inj Human Insulin injection slow infusion I.V. As per blood sugar level
Inj Bicarbonate 200 ml I.V.
K+ Binding resin Sachets Orally.
Urinary catheterization done.
But urine output is nil
To follow below protocol for treatment of this patient.
If RBS > 200 mg/dl —> Give Normal Saline
Doctor asked to repeat following investigation during management
RBS every 2 hourly.
Serum K+ level after 4 hours.
24 hours after admission and intensive care He get consciousness, normal respiration , normal blood pressure & 1200 ml of urine output.
RBS = 150 mg% with Human insulin infusion
Serum acetone = 2 mg/dl
Electrolyte and ABG = Normal.
He shifted to ward & remained admitted for 5 days in hospital.
On discharge, physician advises to take prescribe insulin dose regularly as well as regular follow up with FBS & PP2BS.
1. Give explanation for altered consciousness and increase respiratory rate in this case.
2. What metabolic and functional abnormality can occur due to increase acetone level?
3. Why after 24 hours serum acetone came down nearer to normal level?
4. What is patho-physiology behind decrease urine output in this patient?
5. Give comment on patient ABG report.
6. Give biochemical reason for increase K+ level in this case.
7. What is biochemical reason for giving dextrose saline plus human insulin infusion if RBS is below 200 mg%?
8. How bicarbonate, insulin and K+ binding resin reduce serum potassium level?
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