Cerebral edema prevention and management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Cerebral edema prevention and management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cerebral edema prevention and management US Medical PG Question 1: A 14-year-old female with no past medical history presents to the emergency department with nausea and abdominal pain. On physical examination, her blood pressure is 78/65, her respiratory rate is 30, her breath has a fruity odor, and capillary refill is > 3 seconds. Serum glucose is 820 mg/dL. After starting IV fluids, what is the next best step in the management of this patient?
- A. Intravenous Dextrose in water
- B. Subcutaneous insulin glargine
- C. Intravenous regular insulin (Correct Answer)
- D. Intravenous glucagon
- E. Subcutaneous insulin lispro
Cerebral edema prevention and management Explanation: ***Intravenous regular insulin***
- The patient presents with **diabetic ketoacidosis (DKA)**, characterized by **hyperglycemia**, **fruity breath** (due to ketones), and **hypotension**. Prompt administration of **intravenous regular insulin** is crucial to lower blood glucose and resolve ketoacidosis.
- **Regular insulin** is preferred intravenously due to its **rapid onset** and short duration of action, allowing for precise titration and continuous adjustment based on glucose levels.
*Intravenous Dextrose in water*
- **Dextrose** would further increase the already severely elevated blood glucose level in a patient with DKA, worsening the metabolic derangements.
- Dextrose is typically initiated only after blood glucose drops to safe levels (<200 mg/dL) to prevent **hypoglycemia** during insulin infusion.
*Subcutaneous insulin glargine*
- **Insulin glargine** is a **long-acting insulin** designed for basal insulin coverage, not for acute management of severe hyperglycemia or DKA.
- Its **slow onset of action** and prolonged effect make it unsuitable for the urgent and rapid glucose reduction required in DKA.
*Intravenous glucagon*
- **Glucagon** is a hormone that **raises blood glucose levels**, counteracting the effects of insulin.
- Administering glucagon would exacerbate the severe hyperglycemia present in DKA and is used only in cases of severe hypoglycemia.
*Subcutaneous insulin lispro*
- **Insulin lispro** is a **rapid-acting insulin analog** but is typically given subcutaneously.
- While faster than regular insulin subcutaneously, the **subcutaneous route** has variable absorption in critically ill patients, and the immediate and precisely controllable effect of intravenous regular insulin is needed in DKA.
Cerebral edema prevention and management US Medical PG Question 2: An 8-year old boy is brought to the emergency department because he has been lethargic and has had several episodes of nausea and vomiting for the past day. He has also had increased thirst over the past two months. He has lost 5.4 kg (11.9 lbs) during this time. He is otherwise healthy and has no history of serious illness. His temperature is 37.5 °C (99.5 °F), blood pressure is 95/68 mm Hg, pulse is 110/min, and respirations are 30/min. He is somnolent and slightly confused. His mucous membranes are dry. Laboratory studies show:
Hemoglobin 16.2 g/dL
Leukocyte count 9,500/mm3
Platelet count 380,000/mm3
Serum
Na+ 130 mEq/L
K+ 5.5 mEq/L
Cl- 99 mEq/L
HCO3- 16 mEq/L
Creatinine 1.2 mg/dL
Glucose 570 mg/dL
Ketones positive
Blood gases, arterial
pH 7.25
pCO2 21 mm Hg
Which of the following is the most appropriate next step in management?
- A. Intravenous hydration with 0.45% normal saline and insulin
- B. Intravenous hydration with 5% dextrose solution and 0.45% normal saline
- C. Intravenous sodium bicarbonate
- D. Intravenous hydration with 0.9% normal saline and insulin (Correct Answer)
- E. Intravenous hydration with 0.9% normal saline and potassium chloride
Cerebral edema prevention and management Explanation: ***Intravenous hydration with 0.9% normal saline and insulin***
- This patient presents with **diabetic ketoacidosis (DKA)**, characterized by hyperglycemia (glucose 570 mg/dL), metabolic acidosis (pH 7.25, HCO3- 16 mEq/L, ketones positive), and dehydration (dry mucous membranes, increased thirst, weight loss).
- Initial management of DKA involves aggressive **volume expansion** with **0.9% normal saline** to restore perfusion and reduce hyperglycemia; subsequently, **insulin infusion** is started to correct hyperglycemia and halt ketogenesis.
*Intravenous hydration with 0.45% normal saline and insulin*
- While insulin is crucial, **0.45% normal saline (hypotonic saline)** is generally not the initial fluid of choice for DKA due to the risk of exacerbating cerebral edema, especially in children.
- **Isotonic saline (0.9% normal saline)** is preferred for initial resuscitation to rapidly restore extracellular fluid volume.
*Intravenous hydration with 5% dextrose solution and 0.45% normal saline*
- **5% dextrose solution** should only be added to intravenous fluids when the blood glucose level falls to around 200-250 mg/dL, to prevent hypoglycemia while continuing insulin to resolve ketosis.
- Administering dextrose initially would worsen the existing severe hyperglycemia.
*Intravenous sodium bicarbonate*
- **Sodium bicarbonate** is generally not recommended for mild to moderate DKA due to potential risks like cerebral edema and metabolic alkalosis, and potential paradoxical worsening of CNS acidosis.
- Bicarbonate therapy is reserved for **severe acidosis (pH < 6.9 or 7.0)** with hemodynamic instability or impaired cardiac contractility, which is not the case here.
*Intravenous hydration with 0.9% normal saline and potassium chloride*
- While **0.9% normal saline** is appropriate, this option lacks **insulin therapy**, which is essential for treating DKA by halting ketogenesis and correcting hyperglycemia.
- Although potassium supplementation will be necessary during DKA treatment (as insulin drives K+ into cells and can cause hypokalemia), the most appropriate **next step** is to initiate both fluid resuscitation and insulin therapy together.
- The patient's current potassium level of 5.5 mEq/L is at the upper limit of normal, but reflects total body potassium depletion; potassium should be added to maintenance fluids once adequate urine output is established.
Cerebral edema prevention and management US Medical PG Question 3: A previously healthy 14-year-old girl is brought to the emergency department by her mother because of abdominal pain, nausea, and vomiting for 6 hours. Over the past 6 weeks, she has also had increased frequency of urination, and she has been drinking more water than usual. She has lost 6 kg (13 lb) over the same time period despite having a good appetite. Her temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 32/min, and blood pressure is 94/58 mm Hg. She appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to show which of the following findings?
- A. Excess water retention
- B. Serum glucose concentration > 800 mg/dL
- C. Increased arterial pCO2
- D. Increased arterial blood pH
- E. Decreased total body potassium (Correct Answer)
Cerebral edema prevention and management Explanation: ***Decreased total body potassium***
- This is the correct answer. In **diabetic ketoacidosis (DKA)**, patients have **significant total body potassium depletion** due to osmotic diuresis and urinary losses.
- **Serum potassium may initially appear normal or even elevated** due to acidosis-induced extracellular shift of potassium from cells.
- However, **total body potassium stores are markedly depleted**, and during treatment with insulin and fluids, severe hypokalemia can develop as potassium shifts back intracellularly.
*Excess water retention*
- The patient's symptoms, including **polydipsia**, **polyuria**, and **dry mucous membranes**, indicate **dehydration**, not excessive water retention.
- Her blood pressure of 94/58 mm Hg also suggests **volume depletion**.
*Serum glucose concentration > 800 mg/dL*
- While the patient has significant hyperglycemia (indicated by glucose in urine), **DKA** typically presents with glucose levels between **250-600 mg/dL**.
- Glucose levels >800 mg/dL are more characteristic of **hyperosmolar hyperglycemic state (HHS)**, which is less common in children and usually lacks significant ketosis.
*Increased arterial pCO2*
- The patient exhibits **Kussmaul respirations** (deep and labored breathing) and an increased respiratory rate (32/min), which are compensatory mechanisms for **metabolic acidosis**.
- This compensation leads to **decreased arterial pCO2** as the body tries to blow off CO2 to raise pH.
*Increased arterial blood pH*
- The symptoms, particularly **Kussmaul respirations** and the presence of **ketones** in the urine, strongly suggest **diabetic ketoacidosis (DKA)**.
- DKA is characterized by **severe metabolic acidosis**, meaning the arterial blood pH would be **decreased**, not increased.
Cerebral edema prevention and management US Medical PG Question 4: A boy with diabetic ketoacidosis is admitted to the pediatric intensive care unit for closer monitoring. Peripheral venous access is established. He is treated with IV isotonic saline and started on an insulin infusion. This patient is at the highest risk for which of the following conditions in the next 24 hours?
- A. Cerebral edema (Correct Answer)
- B. Intrinsic kidney injury
- C. Cognitive impairment
- D. Hyperkalemia
- E. Deep venous thrombosis
Cerebral edema prevention and management Explanation: ***Cerebral edema***
- **Cerebral edema** is a severe and potentially fatal complication of **diabetic ketoacidosis (DKA)** treatment, particularly in children.
- It results from a rapid decrease in serum osmolality during treatment, causing water to shift into brain cells.
*Intrinsic kidney injury*
- While dehydration in DKA can lead to **prerenal acute kidney injury**, **intrinsic kidney injury** is less common as an acute risk directly from DKA treatment in the first 24 hours.
- Initial fluid resuscitation often improves renal perfusion, reducing the risk of intrinsic damage unless other predisposing factors are present.
*Cognitive impairment*
- Cognitive impairment after DKA is more commonly observed in the long term, potentially due to recurrent episodes or severe DKA with cerebral edema.
- It is not the most immediate and highest risk acute complication in the short-term (next 24 hours).
*Hyperkalemia*
- Patients with DKA typically present with **hyperkalemia** due to acidosis and insulin deficiency, which resolves with insulin therapy as potassium shifts back into cells.
- The more immediate risk during treatment, especially after initial fluid resuscitation and insulin, is **hypokalemia**, not hyperkalemia, due to the intracellular shift of potassium.
*Deep venous thrombosis*
- **Dehydration** and **hyperviscosity** associated with DKA can increase the risk of **thrombosis**, but **deep venous thrombosis** is not the highest or most immediate acute risk in the next 24 hours.
- **Cerebral edema** is a more specific and life-threatening complication directly related to the treatment of DKA in children.
Cerebral edema prevention and management US Medical PG Question 5: A 14-year-old boy is admitted to the emergency department with acute onset of confusion, malaise, diffuse abdominal pain, nausea, and a single episode of vomiting. He denies ingestion of any suspicious foods, fevers, respiratory symptoms, or any other symptoms preceding his current condition. However, he notes an increase in his liquid consumption and urinary frequency over the last 6 months. On physical examination, he is responsive but somnolent. His blood pressure is 90/50 mm Hg, heart rate is 101/min, respiratory rate is 21/min, temperature is 36.0°C (96.8°F), and SpO2 is 96% on room air. He has facial pallor and dry skin and mucous membranes. His lungs are clear to auscultation, and heart sounds are normal. His abdomen is soft with no rebound tenderness on palpation. Neurological examination is significant for 1+ deep tendon reflexes in all extremities. A dipstick test shows 3+ for ketones and glucose. The patient’s blood tests show the following findings:
RBCs 4.1 million/mm3
Hb 13.7 mg/dL
Hematocrit 56%
Leukocyte count 7,800/mm3
Platelet count 321,000/mm3
Glucose 565 mg/dL
Potassium 5.8 mEq/L
Sodium 136 mEq/L
ALT 15 U/L
AST 17 U/L
Amylase 88 U/L
Bicarbonate 19 mEq/L
BE −3 mEq/L
pH 7.3
pCO2 37 mm Hg
pO2 66 mm Hg
Which of the medications listed below should be administered to the patient intravenously?
- A. Insulin detemir
- B. Regular insulin (Correct Answer)
- C. Cefazolin
- D. Potassium chloride
- E. Isophane insulin
Cerebral edema prevention and management Explanation: **Regular insulin**
- The patient presents with **diabetic ketoacidosis (DKA)**, characterized by **hyperglycemia** (glucose 565 mg/dL), **ketonuria** (ketones 3+), and **metabolic acidosis** (pH 7.3, bicarbonate 19 mEq/L, BE -3 mEq/L). **Intravenous regular insulin** is the cornerstone of DKA treatment to lower blood glucose and resolve ketosis.
- Regular insulin is the only type of insulin that can be administered intravenously and has a **rapid onset** and **short duration of action**, allowing for precise titration and quick correction of severe hyperglycemia and acidosis.
*Insulin detemir*
- **Insulin detemir** is a **long-acting insulin analog** primarily used for basal insulin replacement, not for acute management of severe hyperglycemia or DKA.
- It has a **slow onset of action** (1-2 hours) and a prolonged duration (up to 24 hours), making it unsuitable for the urgent and rapid correction required in DKA.
*Cefazolin*
- **Cefazolin** is a **first-generation cephalosporin antibiotic** used to treat bacterial infections.
- This patient's symptoms are consistent with DKA, not a bacterial infection, and there is no indication for antibiotic therapy.
*Potassium chloride*
- Despite the patient's **hyperkalemia** (potassium 5.8 mEq/L) at presentation, DKA treatment with insulin will shift potassium intracellularly, leading to **hypokalemia**.
- **Potassium chloride** is typically added to IV fluids **after insulin therapy has begun and potassium levels start to drop**, to prevent severe hypokalemia, not as an initial treatment when levels are already high.
*Isophane insulin*
- **Isophane insulin (NPH)** is an **intermediate-acting insulin** that is administered subcutaneously.
- It has a **delayed onset of action** (2-4 hours) and cannot be given intravenously, making it inappropriate for the acute management of DKA.
Cerebral edema prevention and management US Medical PG Question 6: A 48-year-old man presents with DKA. Initial treatment is initiated with fluids and insulin infusion. Labs show glucose 460 mg/dL, pH 7.18, bicarbonate 10 mEq/L, potassium 4.5 mEq/L, and creatinine 2.8 mg/dL (baseline 1.0). After 4 hours, glucose decreases to 380 mg/dL but pH worsens to 7.12, bicarbonate drops to 8 mEq/L, and lactate is 5.2 mmol/L (initially 1.8). Blood pressure is 85/50 mmHg. Evaluate the clinical situation and necessary intervention.
- A. Administer additional fluid bolus for persistent hypotension
- B. Evaluate for sepsis or other concurrent illness causing lactic acidosis (Correct Answer)
- C. Increase insulin infusion rate to accelerate ketone clearance
- D. Add bicarbonate therapy for worsening acidosis
- E. Continue current management as DKA takes time to resolve
Cerebral edema prevention and management Explanation: ***Evaluate for sepsis or other concurrent illness causing lactic acidosis***
- While the blood glucose is responding to insulin, the **worsening metabolic acidosis** and significantly elevated **lactate (5.2 mmol/L)** indicate a secondary process such as **sepsis** or tissue hypoperfusion.
- **Diabetic Ketoacidosis (DKA)** often has a precipitating factor; the combination of **hypotension** and rising lactate suggests **septic shock** or organic ischemia that requires urgent investigation and targeted treatment.
*Administer additional fluid bolus for persistent hypotension*
- Although fluid resuscitation is vital, simply giving more fluids without diagnosing the **underlying cause** of the rising lactate and refractory shock is insufficient.
- **Hypotension** in this context may be secondary to **septic shock** or systemic inflammatory response rather than simple volume depletion from DKA.
*Increase insulin infusion rate to accelerate ketone clearance*
- The current insulin infusion is successfully lowering the blood glucose, but the acidosis is worsening due to **lactic acid**, not just ketones.
- Increasing insulin will not resolve **Type A lactic acidosis** caused by **inadequate tissue oxygenation** or sepsis.
*Add bicarbonate therapy for worsening acidosis*
- **Bicarbonate therapy** is generally not recommended in DKA unless the pH is <6.9, as it can cause **paradoxical cerebral acidosis** and hypokalemia.
- Administering bicarbonate would provide a temporary buffer but would fail to address the **rising lactate** and underlying hemodynamic instability.
*Continue current management as DKA takes time to resolve*
- While DKA resolution is gradual, a **rising lactate** and **falling pH** despite therapy are red flags that indicate the clinical condition is deteriorating.
- Ignoring the **acute kidney injury** (Creatinine 2.8) and persistent **hypotension** increases the risk of multi-organ failure and mortality.
Cerebral edema prevention and management US Medical PG Question 7: A 25-year-old woman with type 1 diabetes presents with DKA. She admits to intentionally withholding insulin to lose weight. This is her fifth DKA admission in 8 months. Current pH is 7.14, glucose 520 mg/dL, bicarbonate 11 mEq/L. Medical costs exceed $150,000 for recurrent admissions. The team is frustrated. Evaluate the comprehensive management approach beyond acute DKA treatment.
- A. Referral to ethics committee for discussion of resource allocation
- B. Involuntary psychiatric commitment for non-compliance
- C. Insulin pump placement to prevent future manipulation
- D. Multidisciplinary approach including psychiatry, eating disorder specialist, diabetes educator, and close outpatient follow-up (Correct Answer)
- E. Standard DKA treatment with discharge to outpatient endocrinology
Cerebral edema prevention and management Explanation: ***Multidisciplinary approach including psychiatry, eating disorder specialist, diabetes educator, and close outpatient follow-up***
- This patient presents with **diabulimia**, a life-threatening eating disorder where Type 1 diabetics restrict insulin for weight control, requiring a **comprehensive care team** to address both physiologic and psychological needs.
- A **multidisciplinary strategy** is essential to reduce the high risk of mortality and frequent **recurrent DKA admissions** by targeting the root cause of non-compliance.
*Referral to ethics committee for discussion of resource allocation*
- While medical costs are high, **withholding treatment** based on cost or resource allocation for a life-threatening condition like DKA is generally unethical.
- The **ethics committee** may assist in complex care plans, but it does not address the primary clinical need for specialized psychiatric and nutritional intervention.
*Involuntary psychiatric commitment for non-compliance*
- **Involuntary commitment** typically requires the patient to be a danger to themselves or others due to a mental illness; insulin omission, while dangerous, often does not meet legal criteria if the patient has **decision-making capacity**.
- Simple **non-compliance** in an adult with capacity is not usually grounds for commitment, and long-term behavioral change is better achieved through voluntary therapeutic engagement.
*Insulin pump placement to prevent future manipulation*
- An **insulin pump** is not a solution as it can still be easily manipulated, disconnected, or the settings altered by a patient determined to restrict insulin.
- Introducing a medical device without addressing the **underlying eating disorder** may actually complicate management and increase the risk of device-related complications.
*Standard DKA treatment with discharge to outpatient endocrinology*
- Given five DKA admissions in 8 months, standard management has already proven **insufficient** and fails to address the unique psychiatric etiology of her condition.
- Discharging to **standard outpatient endocrinology** without specialized eating disorder support ignores the behavioral triggers that lead to recurrent life-threatening metabolic crises.
Cerebral edema prevention and management US Medical PG Question 8: A 55-year-old man with type 2 diabetes and end-stage renal disease on hemodialysis presents with DKA. Initial glucose is 580 mg/dL, pH 7.12, bicarbonate 10 mEq/L, and potassium 6.2 mEq/L. He is fluid overloaded with bilateral crackles and peripheral edema. His last dialysis was 3 days ago. Evaluate the optimal management strategy addressing both DKA and renal failure.
- A. Standard DKA protocol with furosemide for fluid management
- B. Bicarbonate therapy to correct acidosis without fluids
- C. Subcutaneous insulin with no IV fluids due to volume overload
- D. Insulin infusion with limited fluids and urgent hemodialysis (Correct Answer)
- E. Standard DKA protocol with aggressive fluid resuscitation
Cerebral edema prevention and management Explanation: ***Insulin infusion with limited fluids and urgent hemodialysis***
- Patients with **ESRD** and **DKA** who are **fluid overloaded** require **urgent hemodialysis** to safely correct metabolic acidosis, hyperkalemia, and volume status.
- **Continuous insulin infusion** is essential to stop ketone production, but fluid resuscitation must be severely **restricted** to avoid worsening pulmonary edema.
*Standard DKA protocol with furosemide for fluid management*
- **Furosemide** is ineffective in patients with **end-stage renal disease** (ESRD) as they have minimal to no residual renal function.
- Standard DKA protocols prioritize aggressive IV fluids, which would be **life-threatening** for a patient already showing signs of volume overload and crackles.
*Bicarbonate therapy to correct acidosis without fluids*
- **Bicarbonate therapy** is generally not recommended for DKA unless the pH is below 6.9, and it can cause a **rebound worsening** of intracellular acidosis.
- It does not address the underlying **insulin deficiency** or the patient's massive **volume overload** and hyperkalemia.
*Subcutaneous insulin with no IV fluids due to volume overload*
- **Subcutaneous insulin** is inappropriate for severe DKA (pH 7.12); **intravenous insulin** is the standard for rapid titration and metabolic control.
- Complete avoidance of fluids may prevent correction of the **osmotic shift**, but the primary failure here is the omission of dialysis for a symptomatic ESRD patient.
*Standard DKA protocol with aggressive fluid resuscitation*
- Aggressive fluid administration is **contraindicated** in ESRD patients with clinical signs of **congestive heart failure** like crackles and peripheral edema.
- This approach carries a high risk of inducing **acute respiratory failure** or flash pulmonary edema.
Cerebral edema prevention and management US Medical PG Question 9: A 38-year-old pregnant woman at 28 weeks gestation with type 1 diabetes presents with nausea and vomiting. Labs show glucose 310 mg/dL, pH 7.27, bicarbonate 15 mEq/L, and positive urine ketones. Fetal monitoring shows reactive non-stress test. She has been taking her insulin but unable to eat for 24 hours due to hyperemesis. Analyze the optimal management approach considering maternal and fetal risks.
- A. Standard DKA protocol with standard glucose targets (200-250 mg/dL)
- B. Aggressive DKA treatment with lower glucose targets (100-150 mg/dL) and close fetal monitoring (Correct Answer)
- C. Immediate cesarean delivery followed by DKA treatment
- D. Conservative management with oral intake and subcutaneous insulin
- E. Standard DKA protocol with delivery planning after stabilization
Cerebral edema prevention and management Explanation: ***Aggressive DKA treatment with lower glucose targets (100-150 mg/dL) and close fetal monitoring***
- In pregnancy, **Diabetic Ketoacidosis (DKA)** often presents with lower blood glucose levels due to increased **glucose utilization** by the fetus and placenta.
- Successful management requires **aggressive hydration**, **intravenous insulin**, and maintaining blood glucose between **100-150 mg/dL** to prevent fetal complications.
*Standard DKA protocol with standard glucose targets (200-250 mg/dL)*
- Standard targets for non-pregnant adults are too high for pregnancy and can lead to prolonged **fetal acidosis** and increased morbidity.
- Pregnancy-specific protocols prioritize tighter glycemic control to optimize the **maternal-fetal environment** during acute metabolic distress.
*Immediate cesarean delivery followed by DKA treatment*
- Surgery during **untreated DKA** carries extremely high maternal and fetal risk; the fetus should only be delivered for **obstetric indications** after maternal stabilization.
- **Fetal heart rate** abnormalities often resolve once the mother's **acidosis** and electrolyte imbalances are corrected with medical therapy.
*Conservative management with oral intake and subcutaneous insulin*
- Maternal **acidemia (pH 7.27)** and **ketonuria** indicate a medical emergency that cannot be safely managed with subcutaneous insulin or oral fluids.
- **Nausea and vomiting** from hyperemesis or the DKA itself necessitate **intravenous fluid resuscitation** and specialized inpatient monitoring.
*Standard DKA protocol with delivery planning after stabilization*
- While maternal stabilization is the primary goal, following a "standard" protocol ignores the need for **lower glucose targets** unique to pregnancy.
- **Delivery planning** at 28 weeks should only be considered if fetal distress persists after maternal metabolic status has returned to baseline.
Cerebral edema prevention and management US Medical PG Question 10: A 42-year-old man with type 1 diabetes on insulin pump presents with DKA after pump malfunction. He is admitted and started on IV insulin infusion. After 14 hours of treatment, his glucose is 210 mg/dL on D5-0.45% saline, pH 7.36, bicarbonate 19 mEq/L, and anion gap 12. He is alert, eating, and requesting to go home. Evaluate the appropriate transition strategy.
- A. Switch to subcutaneous insulin and discharge immediately
- B. Stop IV insulin immediately and restart insulin pump at home
- C. Continue IV insulin for another 6 hours to ensure stability
- D. Give subcutaneous insulin, overlap for 1-2 hours, then stop IV insulin and observe (Correct Answer)
- E. Discontinue IV insulin, discharge with oral medications
Cerebral edema prevention and management Explanation: ***Give subcutaneous insulin, overlap for 1-2 hours, then stop IV insulin and observe***
- DKA is considered resolved when the **anion gap** is <12, **bicarbonate** is ≥18, and **pH** >7.3; once resolved, transitioning to **subcutaneous insulin** is appropriate if the patient is eating.
- An **overlap period of 1-2 hours** between the administration of subcutaneous insulin and the cessation of the **IV insulin infusion** is mandatory to prevent the recurrence of ketoacidosis due to the short half-life of IV insulin.
*Switch to subcutaneous insulin and discharge immediately*
- While the transition to subcutaneous insulin is correct, **immediate discharge** is unsafe as the patient must be observed for metabolic stability after the transition.
- Adequate time must be allowed for **absorption of subcutaneous insulin** and verification that the patient can maintain glycemic control while off the infusion.
*Stop IV insulin immediately and restart insulin pump at home*
- Stopping IV insulin **immediately** without an overlap period leads to a rapid decline in serum insulin levels and risks a **rebound of ketosis**.
- Relying on the patient to restart a potentially **malfunctioning pump** at home without inpatient supervision increases the risk of treatment failure.
*Continue IV insulin for another 6 hours to ensure stability*
- **Prolonging IV insulin** after the resolution of DKA and normalization of the anion gap is unnecessary and increases the risk of **hypoglycemia** and **hypokalemia**.
- Since the patient is alert and **eating**, they meet the criteria for transitioning to a subcutaneous regimen to facilitate a return to normal metabolic management.
*Discontinue IV insulin, discharge with oral medications*
- **Type 1 diabetic** patients have an absolute insulin deficiency and always require exogenous insulin; **oral medications** are inappropriate for managing T1DM.
- Discontinuing insulin therapy in a T1DM patient will inevitably lead to the return of **hyperglycemia** and life-threatening **diabetic ketoacidosis**.
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