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Surgery

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General Surgery

Question
104 out of 142
 

A 60-year-old woman is admitted to the emerge-ncy department with evidence of spreading perito-nitis. Her temperature is 40°C with a pulse rate of 120/min and blood pressure of 96/60. Her blood sugar is 960 mg%. Urine specific gravity is 1.030, and marked glucosuria and ketonuria are present. The most important first step in her management is



A Administration of broad-spectrum antibiotics intravenously

B Correction of hyperglycemia

C Correction of ketoacidosis

D Immediate diagnostic celiotomy

Ans. C Correction of ketoacidosis (REF. HARRISON INTERNAL MEDICINE, 18TH EDN PG 930)

a. DKA results from relative or absolute insulin deficiency combined with counter regulatory hormone excess (glucagon, catecholamines, cortisol, and growth hormonE.. Both insulin deficiency and glucagon excess, in particular, are necessary for DKA to develop.

b. The decreased ratio of insulin to glucagon promotes gluconeogenesis, glycogenolysis, and ketone body formation in the liver, as well as increases in substrate delivery from fat and muscle (free fatty acids, amino acids) to the liver.

c. DKA is initiated by inadequate levels of plasma insulin.

d. Most commonly, DKA is precipitated by increased insulin requirements, as might occur during a concurrent illness. Failure to augment insulin therapy often compounds the problem.

e. Occasionally, complete omission of insulin by the patient or health care team (in a hospitalized patient with type 1 DM) precipitates DKA.

f. Patients using insulin infusion devices with short-acting insulin are at increased risk of DKA, since even a brief interruption in insulin delivery (e.g., mechanical malfunction) quickly leads to insulin deficiency.

Management of Diabetic Ketoacidosis

a. Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis).

b. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH < 7.00 or unconscious.

c. Assess:

Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphatE.

Acid-base status—pH, HCO3-, PCO2, b-hydroxybutyrate

Renal function (creatinine, urine output)

d. Replace fluids: 2–3 L of 0.9% saline over first 1–3 h (10–15 mL/kg per hour); subsequently, 0.45% saline at 150–300 mL/h; change to 5% glucose and 0.45% saline at 100–200 mL/h when plasma glucose reaches 250 mg/dL (14 mmol/L).

e. Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3 units/kg), then 0.1 units/kg per hour by continuous IV infusion; increase 2- to 3-fold if no response by 2–4 h. If initial serum potassium is < 3.3 mmol/L (3.3 meq/L), do not administer insulin until the potassium is corrected to > 3.3 mmol/L (3.3.meq/L).

f. Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocainE.? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).

g. Measure capillary glucose every 1–2 h; measure electrolytes (especially K+, bicarbonate, phosphatE. and anion gap every 4 h for first 24 h.

h. Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 1–4 h.

i. Replace K+: 10 meq/h when plasma K+ < 5.5 meq/L, ECG normal, urine flow and normal creatinine documented; administer 40–80 meq/h when plasma K+ < 3.5 meq/L or if bicarbonate is given.

j. Continue above until patient is stable, glucose goal is 150–250 mg/dL, and acidosis is resolved. Insulin infusion may be decreased to 0.05–0.1 units/kg per hour.

k. Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection.

General Surgery Flashcard List

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