August 17th, 2020
We talked about a 50 year old female with T1DM presenting with 3 days of refractory n/v and diarrhea. Initial BMP concerning for Na+ of 112, K+ of 4, mild acidosis with gap of 15 and glucose of 230. Beta-hydroxybutyrate not initially checked. Remember, in patients with T1DM DKA can occur at lower glucose levels than we typically think of, and that in patients with hyponatremia rapid correction should only occur if patients are hemodynamically unstable due to the sodium level (ie seizing).
For any K+ <5.5 start fluids with potassium at same time you start insulin drip.
For K+ <3.3 replace K+ with IV K+ to at least >3.5 PRIOR to starting an insulin drip to prevent life threatening and rapid hypokalemia.
This patient has no had her Na+ checked since 2012 so assume >48 hours at this level and no rapid correction unless hemodynamically unstable.
Aim for correction of 10meq in 24h. If it appears trajectory is going to quickly can turn off normal saline and bolus 500cc D5W, typically try this at the next check if still going to quickly. By third Na+ check if still need to slow down use DDAVP.
Type 1 diabetes in the hospital:
Never hold their long act insulin. If they are NPO and running on the lower side can consider reducing by 10% their home dose but they require long acting insulin.