Case 3 A 21-year-old woman with an eight-year history of juvenile onset diabetes

Question

Case 3 A 21-year-old woman with an eight-year history of juvenile onset diabetes was brought to the hospital in a coma. She had required 92 units of insulin daily to maintain her blood glucose concentration in ar acceptable range and prevent excessive glucosuria. On admission she had a BP of 92/20 mmHg, a pulse of 122 beats/min, and deep respirations of 32/min. Lab data showed: ABG: - 15 mmHg pH po2 Serum Chemistry Values: Na pCO2 90 mmHg HCO3 = 4 mmol/L - 6.4 mmol/L - 5 mmol/L = 74 mg/dL = 129 mmol/L | K. Cl 95 mmol/L : total CO2 glucose 1200 mg/dL urea nitrogen creatinine2.3 mg/dL 1. What is the nature and etiology of the acid-base disturbance? 2. Is there indication for a normal compensatory response? 3. Explain the abnormal serum potassium result. 4. Explain the abnormal serum sodium result.

Explanation / Answer

1.NATURE AND ETIOLOGY OF ACID-BASE DISTURBANCE:- ACCORDING TO THE HISTORY OF THE PATIENT THE PATIENT HAS UNDERGONE DIABETIC COMA WHICH USUALLY OCCUR DUE TO EXTREMELY HIGH BLOOD GLUCOSE LEVEL, i.e. 1200mg/dl IN THE PATIENT, IT IS ALSO KNOWN AS HYPERGLYCEMIC HYPEROSMOLAR SYNDROME, IN THIS PATIENT FEELS THIRST AND NEED TO URINATE MORE FREQUENTLY, SO DUE TO FREQUENT EXCESSIVE URINATION FLUID LOSS INCREASES WHICH LEADS TO DECREASED SODIUM LEVEL, i.e. 129mmol/L IN PATIENT.

2.INDICATION OF NORAMAL COMPENSATORY RESPONSE:- AS POTASSIUM LEVEL DECREASES MEANS THE BODY IS RECOVERING BACK FROM THE METABOLIC ACIDOSIS. MONITOR CONTINUOUSLY THE LEVEL OF POTASSIUM AND ADMINSTER IF NEEDED TO PREVENT FURTHER COMPLICATIONS.

ALSO INCREASED RESPIRATION RATE IS THE COMPENSATORY MECHANISM OF THE LUNGS.

3.ABNORMAL SERUM POTASSIUM RESULT:- DURING THE ACIDOSIS CONDITION, PARTICULARLY OF DIABETIC TYPE, THERE IS IMMEDIATE AND INCREASING LOSS OF POTASSIUM IN THE URINE.THIS POTASSIUM COMES CHIEFLY FROM THE CELLS THROUGH DISTURBANCE IN CELLULAR PERMEABILITY OCCURING DURING DIABETIC COMA, AND IN CASE OF DIBAETIC COMA IT MAY BE SEVERE.

4.ABNORMAL SERUM SODIUM RESULT:- WHEN GLICOSE LEVEL IS UNCONTROLLED IN THE BODY OR THE UNCONTROLLED DIABETIC MELLITUS CAN ALSO INDUCE HYPOVOLEMIC-HYPONATREMIA (DECREASE IN SODIUM LEVEL) DUE TO OSMOTIC DIURESIS, ALSO IN CASE OF DIABETIC KETOACIDOSIS, KETONE BODIES CAUSE INCREASED ELECTROLYTE LOSS AND AGGRAVATES THE RENAL SODIUM WASTING.

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