Case:

A 44 year-old diabetic with chronic alcoholism was admitted to LUMC in a coma. The patient was well until 2 days prior to admission when he developed nausea, vomiting, and anorexia as an aftermath of St. Patrick's Day. He failed to take his split dose of NPH and regular insulin and the following day became confused and then comatose.

On admission, the patient was unresponsive with BP of 88/68 mm Hg, a pulse rate of 120 per minute, a rectal temperature of 370C, and a respiratory rate of 42 per minute with Kussmaul breathing. He appeared dehydrated, but the remainder of the examination was normal.

The hemoglobin was 15.3 gm/dl, the hematocrit 48 vol%, and the leukocyte count was 13,500 with a left shift. The bladder contained 60 ml of urine with a specific gravity of 1.022, a pH of 5.5, 2.0 gm/dl glycosuria, 2 + proteinuria, strong positively for ketones and the sediment was unremarkable. The initial blood glucose was 866 mg/dl, serum B-OH butyric acid was 4, the BUN was 69 mg/dl, the serum creatinine was 1.0 mg/dl, and a blood ethanol level was zero. The serum sodium was 127 mEq/L, potassium 5.1 mEq/L, chloride 90 mEq/L, C02 content 5 mEq/L. Arterial blood had PH 7.1, pCO2 10 mm Hg, pO2 114 mm Hg, and bicarbonate 2 mM/L. HgbA1C was 9.5%.

Therapy for diabetic ketoacidosis was initiated with 10 U of Humalog insulin IV push followed by 10u/hr IV with normal saline at a rate of 1 liter per hour. In the first 12 hours of therapy, the patient received 120 units of insulin, 4.5 liters of normal saline, and 230 mEq of potassium chloride. During this period his vital signs returned to normal. blood glucose decreased to 99 mg/dl, CO2 increased to 17 mEq/L, arterial pH increased to 7.36, and serum potassium decreased to 3.0 mEq/L. As urine output averaged 400 ml/hr, BUN decreased from 69 to 34 mg/dl, and plasma ketones became undetectable. Despite clearing of acidosis and restoration of plasma glucose to normal, the patient failed to regain consciousness and showed increasing evidence of neuromuscular irritability with generalized twitching, hyperreflexia, and sustained ankle clonus. By the next morning, the patient stabilized, regained consciousness and began to eat.

His insulin drip was discontinued, and on the 3rd hospital day he was started on 30 units NPH + 10 units Humalog at breakfast and 20 units NPH and 10 units Humalog at dinner. During his dinner meal he developed the acute onset of chest tightness and his EKG revealed new ischemic changes. A cardiac cath demonstrated a 95% occlusion of his LAD and the patient underwent an emergent bypass procedure. His BS was 258 mg/dl and insulin drip was initiated at 10 u/hr. His perioperative and post-op courses were unremarkable with blood sugars between 90-140 mg/dl.

On the 5th post-op day he was discharged on 35 units NPH + 10 units Humalog at breakfast and 25 units NPH + 10 units Humalog at dinner. Upon returning to clinic 1 week after discharge, he complained of nightmares at 2 AM and of waking up with headaches. His FBS levels were 160-180 mg/dl and ranged 110-160 mg/dl throughout the day.