Conversational decision support system post COVID ?misc

DR.CS:https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html

18yr male with hyperbilirubinemia secondary to ?gilbert ?Criggler najjar 

DKA (resolved)

?denovo type 1 Dm

C/o severe low back ache with tenderness + on examination

His

LFT on 11/6/2021 total bilirubin 6.7,direct 3.9,indirect 2.8,Ast,AlT,albumin normal

On 12/6/2021 total bilirubin 8,direct 2, indirect 6,AST,ALT normal,ALP 

On 14/6/2021 total bilirubin 6,direct 4.5,indirect 1.5,AsT AlT normal,AlP 150

UsG abdomen :normal

Pt has severe LBA since 1week and tenderness + sir

Is there any sacroilitis sir?

Dr.ZA: Subjectively-c/o lethargy from today afternoon. Did not pass urine the entire day.

Objectively- pt is drowsy not responding to verbal commands, responding to painful stimulus , giving bizarre starey looks occasionally.

BP-110/70

PR-70bpm regular normal volume

Abdomen- Palpable bladder

Assessment- ? Absence seizure / ? Intra parenchymal bleed

Plan-sr electrolytes sent

CT brain planned now

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html

Dark coloured urine after placing foleys

[6/15/2021, 9:05 PM] K.V: Can this patient have porphyria sir ?

[6/15/2021, 9:16 PM] RB: Or Cola colored urine suggestive of intravascular hemolysis.

[6/15/2021, 9:17 PM] RB: The low backache can be due to hemolytic vaso-occlusive crisis!

[6/15/2021, 9:28 PM] K.V: Yes sir..but ldh is normal and hemoglobin also

[6/15/2021, 9:28 PM] AD: His initial cue showed 3 plus albuminuria 

And now has dark coloured urine. 

Could be ATN? 

We could repeat his cue

[6/15/2021, 9:30 PM] AD: His hemoglobin is 16.5 sir

[6/15/2021, 9:41 PM] RB: Repeat his hemogram. 

What was his creatinine earlier?

[6/15/2021, 9:42 PM] K.V: His creat is 0.6 today evening report sir

[6/15/2021, 9:47 PM] RB: Did his acidosis subside in repeat ABG?and blood sugar charts?

Dr.CS:Ph 7.41

Pco2 27

Hco3 17.. 30mins ago sir

[6/15/2021, 9:57 PM] Dr. CS: Today 8am 95

2pm 115

6pm 103

His sugars are under control sir

[6/15/2021, 9:58 PM] Dr ZA: 8pm-120

[6/15/2021, 10:24 PM] CS: PT 30

INR 2.2

APTT 58

Yesterday mrng report sir

[6/15/2021, 10:25 PM] RB: Controlled on how much of insulin daily?

[6/15/2021, 10:27 PM] RB: Suggestive of liver failure? 

Serum albumin?

[6/15/2021, 10:27 PM] CS: Not more than 6-8units actrapid entire day sir

Due to nausea pt is not eating properly

[6/15/2021, 10:28 PM] RB: Yesterday?

[6/15/2021, 10:28 PM] CS: Albumin 4.3 sir

[6/15/2021, 10:29 PM] CS: Yes sir.today mrng 4units actrpid given.

Afternoon we did not give insulin as grbs was 115 and he was not eating anything because of nausea

[6/15/2021, 10:30 PM] RB: Acute liver failure with deranged coagulation factors as it's half life is much smaller than albumin?

[6/15/2021, 10:30 PM] CS: Yes sir

[6/15/2021, 10:31 PM] RB: He probably didn't have DKA. 

This is an infection or toxin causing acute liver failure.

? Malaria 

Please share his updated fever chart

[6/15/2021, 10:40 PM] CS: First day of admission he had one spike of 101 sir

After that no fever spikes

This is a data corrupted chart with lines drawn without points?

[6/15/2021, 10:55 PM] K.V: But sir how do we explain sugars of 280-360 intially and also hba1c of 6.6 % . Ketones were postive and also mild acidosis

[6/16/2021, 7:36 AM] RB: Acute pancreatic failure along with liver failure

[6/16/2021, 7:36 AM] RB: Share his covid test and chest X-ray

[6/16/2021, 7:37 AM] RB: It's transient AGN

[6/16/2021, 7:38 AM] RB: Similar to the AGN epidemic we have been witnessing. It's either a covid variant or some hitherto undescribed virus or other antigen

[6/16/2021, 7:39 AM] RB: Let's get his urine for porphobilinogen. Given the history I would prioritise my money on an infective immune mediated etiology first before I put my money on a metabolic cause

CNS vasculitis. Reminds me of the previous patient with subconjunctival hemorrhage and AGN in the next bed

[6/16/2021, 12:55 PM] CS:

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html

?Non convulsive status epilepticus

Acute liver failure with ?acute pancreatic failure ?Toxin mediated

Hepatic encephalopathy 

Hepatic coagulopathy

?acute intermittent porphyria

Diabetic ketoacidosis (resolved)

?denovo diabetes type 1

Patient became drowsy and not responding to verbal communication since yesterday evening with acute retention of urine,bizarre starey looks, responding to painful stimuli

?absence seizure

Inj. Loraz 2cc given yesterday night

CT brain done- normal

O/E-

GCS-E2 V2 M3

Pupils-B/L RL dilated

BP -130/80 mmHg

PR-70 bpm

Temp- 100F

CVS- S1,S2 heard

RS- BAE 

 *EEG is not working sir*

[6/16/2021, 1:17PM]RB:Let's treat him for falciparum malaria 

Get his EEG from LB Nagar?

[6/18/2021, 4:00 PM] AD: Sir I think this patient 18 yr old male may have Reyes syndrome...

[6/18/2021, 4:20 PM] RB: 👏 good point. 

Substantiate with further pointers to Reyes syndrome features that our current patient has

[6/18/2021, 4:24 PM] RB: Tally some of the features in our current patient with those mentioned here https://rarediseases.org/rare-diseases/reye-syndrome/

[6/18/2021, 4:28 PM] Dr.AD: according to the elog made on the patient , the patient has fever 10 days prior and he was taken to the rmp and his fever relieved upon medication and after 7 days of fever the patient developed jaundice , vomitings and diarrhea. he is a known case of type1dm and is dka. there is hyperammonemia which leads to hepatic encephalopathy. the patient might have been given salicylates for his fever(not known definitely)

[6/18/2021, 4:32 PM] Dr.AD: Vomitings

Diarrhea

Loss of consciousness

Dilated pupils

Sezuires

Hyperammonemia 

And his crp is within normal range

[6/18/2021, 4:44 PM] RB: What is the evidence for hyperammonemia or seizures in our patient?

[6/18/2021, 4:45 PM] RB: What is the pathophysiology of pupillary dilatation in Reyes?

K.V: :https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1

18 year old male with acute fulminant hepatic failure and hepatic encphelapathy ( ? MISC /? Toxin /? Infections ).pt having repeated? epileptic cries.

[6/19/2021, 7:46 AM] RB: Did he regain consciousness in between or did he remain mid brain dead?

[6/19/2021, 7:48 AM] RB: Slight rephrasing of diagnosis required after yesterday's discussion. 

18M with hemolysis, coagulopathy and encephalopathy possibly related to MISC with Reyes as a close differential

[6/19/2021, 7:48 AM] RB: Do we have his parental permission to share his identifiers in a group?

[6/19/2021, 7:50 AM] Dr.Ch: Sir the video has been pixelated

[6/19/2021, 7:52 AM] RB: The area around his face needs more pixellation and perhaps then it may be shareable as a YouTube linked video inside his case report?

[6/19/2021, 7:53 AM] K.V: RTPCR Negative sir

[6/19/2021, 7:54 AM] RB: What is the incidence of covid negativity in MISC?

[6/19/2021, 7:54 AM] K.V: It's possible sir..we can consider MISC even if covid negative and antibodies are positive

[6/19/2021, 8:02 AM] RB: Share some instances in the literature where this consideration was supported. Also why not Reyes?

[6/19/2021, 8:41 PM] RB: 18year old male with acute liver failure

Icu first bed

Yesterday gastro sir has told to withhold steroids sir,but yesterday during mrng rounds one dose of steroids (inj dexa 6mg stat) was given, after that it wasnt given till now sir

3%NaCl and N acetyl cystiene infusions are being given 

Today eveng his sensorium improved drastically

He was irritable and completely came into consciousness,he asked us to leave him not to restrain him and not to give any injections

He was even asking his mother about his bike.

As he is improving we have a doubt regarding starting the steroids sir.should we continue or withhold dexamethasone??

[6/19/2021, 8:41 PM] RB: Let's withhold

[6/19/2021, 8:41 PM] RB: NAC for PCM poisoning? 

Did he also have significant hyponatremia?

[6/19/2021, 8:41 PM] CS: No sir .we gave 3%Nacl with suspicion of any cerebral edema

And NAC for unexplained liver failure,it is also used in acute non acetaminophen liver failure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470376/

randomized case control study was conducted with the aim to determine the effect of NAC on the mortality of NAI-ALF patients, as well as to evaluate the safety and efficacy of NAC use.

Patient

A total of 80 patients diagnosed with NAI-ALF were included in the study

I Forty patients received NAC infusion for 72 h whereas the control group received placebo

O The mortality decreased to 28% with the use of NAC versus 53% in the control group (P = 0.023). The use of NAC was associated with shorter length of hospital stay in survived patients (P = 0.002). Moreover, the survival of patients was improved by NAC (P = 0.025). Also, drug-induced ALF showed improved outcome compared to other etiologies

[6/19/2021, 8:43 PM] K.V: Yes sir n acetyl cysteine showed improvement even in non acetaminophen induced liver failure..so we started infusion yesterday

[6/19/2021, 8:44 PM] K.V: NAC is a thiol-containing agent that scavenges free oxygen radicals and replenishes cellular, mitochondrial, and cytosolic glutathione stores by serving as a source of a glutathione surrogate that combines directly with reactive metabolites or serves as a source of sulfate, thus preventing hepatic damage.[30,31,32] Moreover, various trials have proved the anti-inflammatory, antioxidant, inotropic, and vasodilating effects of NAC.[33,34] NAC benefits NAI-ALF patients either by improving systemic hemodynamics and tissue oxygen delivery

................

[6/20/2021, 8:44 PM] K.V:18 yr old male - Acute fulminant hepatic failure . Hepatic encphelapathy - completely resolved.

Pt conscious and responding to commands . Able to walk on his own .

No more seizure episodes

Bp- 110/80 mmHg

Pr - 80BPM

Temp - Afebrile .

[6/20/2021, 6:36 PM] RB: 👏👏 great to see this

[6/20/2021, 6:39 PM] AD: 👏🏻👏🏻

[6/20/2021, 6:49 PM] RA: Heard of miracle but speculating it for the first time😀

[6/20/2021, 6:55 PM] K.V: Yes it's like some movie..pt woke up from coma and is walking😅 we dont really know to what he responded sir ..may be IV doxy ,3% Nacl , NAC , or repeated enema /lactulose removing all of his ammonia .

[6/20/2021, 8:15 PM] RB: Or just time?

[6/20/2021, 8:18 PM] K.V: Most likely sir...his inflammation subsided and he must've recovered

[6/20/2021, 8:21 PM] RB: But what made it subside? If we say it was time then it would appear as if it was programmed to happen without any external intervention.

If we say it was his parents prayers we are not sure how it reached the inflammatory battlefield inside different areas of his body. 

If we say it was the discussions (prayers) in our 2-4 PM sessions with learning outcomes driving patient outcomes, the connection would appear even more magical!

[6/21/2021, 6:47 AM] CS:

His repeat LFT

TB 14.3

DB 9.6

ALT 4.6

AST 750

ALP 190

TP 6.2

 *Alb 2.5* 

Glb 3.7

A/G 0.6

Serum ammonia :108 (Normal range)

Urine for porphobilinogen negative

Both direct and indirect bilirubin are high sir

? Hemolysis and intra hepatic cholestasis

Yesterday night he had one more episode of ?absence seizure where he had loss of awareness of surroundings with staring look and repeating a single word for about 15mins

COVID antibodies came positive sir

[6/21/2021, 7:41 AM] RB: What is the specificity of this test for covid? 👏

[6/21/2021, 7:42 AM] RB: Are we sure ALT is 4.6 only while AST is 750!

If true then what is the reason for increased enzymatic activity leading to depletion of ALT?

[6/21/2021, 7:44 AM] K.V: Indirect bilirubin is 4.6 sir 

Sgot - 190

Sgpt -750

Alp-113

[6/21/2021, 7:46 AM] CS: Sry sir it is IB

[6/21/2021, 7:47 AM] RB: IB full form? Intelligence bureaue?

[6/21/2021, 7:48 AM] CS: Indirect bilirubin sir😂

[6/21/2021, 7:48 AM] RB: Got it 👍

[6/21/2021, 7:49 AM] RB: This also suggests that it is liver failure after all although difficult to explain the absence of transaminitis in his first LFT

[6/21/2021, 7:52 AM] RB: Is this a first unique covid case report in the world presenting with MISC and liver failure?

DR.K.V:

[6/21/2021, 7:59 AM] RB: What was the method employed in our patient?

[6/21/2021, 8:00 AM] K.V: ELISA AND CLIA

[6/21/2021, 8:00 AM] RB: Also this is just reflecting sensitivity not specificity?

[6/21/2021, 8:01 AM] RB: What was this study's (these studies) gold standard for comparison?

[6/21/2021, 8:01 AM] K.V: sir it's mostly MISC and since the start his presentation was so atypical..it wasn't fitting into anything else

[6/21/2021, 8:01 AM] RB: That's still our convenient assumption? Let's try to quantify it scientifically

[6/21/2021, 8:04 AM] RB: When we say 84% True positive for covid with ELISA do we also mean 16% True negative with virus isolation as the gold standard (giving a specificity of 84%)?

[6/21/2021, 4:27 PM] RB:Good evening sir. Today you had discussed a case of an 18 year old boy with hepatic encephalopathy which was suspected to be a result of COVID 19. I found a few articles on PubMed and prime. These have been documented in pediatric age groups. One boy is 14 and one is 11.

[6/21/2021, 4:27 PM] RB: 👆from 2019 batch student

[6/22/2021, 12:06 PM] RB: Multisystem inflammatory syndrome in children (MIS-C) is a rare but severe complication of SARS-CoV-2 infection in children and adolescents. Since June 2020, several case reports and series have been published reporting a similar multisystem inflammatory syndrome in adults (MIS-A).

Cases reported to CDC and published case reports and series identify MIS-A in adults, who usually require intensive care and can have fatal outcomes. Antibody testing was required to identify SARS-CoV-2 infection in approximately one third of 27 cases.

During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States (1–3). Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6 (1). Since June 2020, several case reports have described a similar syndrome in adults; 

These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition.

Two clinician reviewers selected patients who fulfilled the working MIS-A case definition used in this report, which included the following five criteria: 1) a severe illness requiring hospitalization in a person aged ≥21 years; 2) a positive test result for current or previous SARS-CoV-2 infection (nucleic acid, antigen, or antibody) during admission or in the previous 12 weeks; 3) severe dysfunction of one or more extrapulmonary organ systems (e.g., hypotension or shock, cardiac dysfunction, arterial or venous thrombosis or thromboembolism, or acute liver injury); 4) laboratory evidence of severe inflammation (e.g., elevated CRP, ferritin, D-dimer, or interleukin-6); and 5) absence of severe respiratory illness (to exclude patients in which inflammation and organ dysfunction might be attributable simply to tissue hypoxia).

[6/22/2021, 12:06 PM] RB: The interval between infection and development of MIS-A is unclear, adding to uncertainty regarding whether MIS-A represents a manifestation of acute infection or an entirely postacute phenomenon. In patients with COVID-19, dyspnea is typically experienced a median of 5–8 days and critical illness 10–12 days after onset of symptoms.§ In patients who reported typical COVID-19 symptoms before MIS-A onset, MIS-A was experienced approximately 2–5 weeks later. However, eight MIS-A patients reported no preceding respiratory symptoms, making it difficult to estimate when initial infection occurred.

[6/22/2021, 12:06 PM] RB

https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm

..........

March 25 2022

Unit 4

New admission 

Amc bed 6 : 

19 yrs old male patient came to the casuality with c/o vomitings since 1 day, c/o SOB since yesterday afternoon. 

Patient was apparently asymptomatic 2 days back then he developed nausea & vomitings, 10 episodes since day before yesterday afternoon, food as content, non projectile, non bilious. 

No c/o fever, loose stools, pain abdomen , cough, cold, burning micturition. 

Patient is a known case of type 1 Diabetes mellitus since 9 months , using insulin 

HAI 26---- 26----- 35

NPH 26-----x-------35

Patient didn't miss his insulin, patient is using insulin regularly 

Patient got admitted in October 2021 with DKA was discharged on 

HAI 26---- 26----- 35

NPH 26-----x-------35

In June 2021 there is a h/o Acute fulminant hepatic failure ,hepatic encephalopathy, coagulopathy, Post covid MISC, DKA ( denovo detected DM) , metabolic seizures ( absence seizures)    

O/E : 

Pt is c/c/c 

Vitals : 

Temp: 99.8 f

HR: 78 bpm

RR : 20cpm

BP : 130/90 mm hg

Spo2: 99 @ RA

GRBS :

At admission : 361 mg/dl --6U IV / stat given 

2 am 318 HAI @ 5 ml / hr

3am 328 HAI @ 5ml / hr

4am 272 HAI @ 5ml / hr

5am 216 HAI @ 5 ml / hr

6am 170 HAI @ 5 ml / hr

7am 154 HAI @ 5 ml / hr

8am 140 HAI @ 5 ml / hr --- started D5 @ 100 ml / hr

SYSTEMIC EXAMINATION : 

CVS : S1 S2 + . 

RS : BAE + NVBS + 

PA: mild tenderness in epigastric region 

CNS : NAD 

Diagnosis : Diabetic ketoacidosis secondary to ? acute gastroenteritis 

TREATMENT :

NS 3 Litres bolus given 

IVF - NS, RL @ 200 ml / hr

Inj. HUMAN ACTRAPID 6U IV / stat given (361---> 297)

Inj. HUMAN ACTRAPID 40U in 39ml NS @ 5 ml /hr 

Nill by mouth 

Inj. PANTOP 40 mg IV / OD 

Inj. Zofer 4mg IV /TID 

INJ. NEOMOL 1 gm IV /SOS ( if temp > 101 F)  

Tab. DOLO 650 mg PO/ TID 

Urine for ketone bodies : positive 

ABG : 

pH : 7.10

 pCO2 : 6.0

HCO3 : 1.8 

S HCO3 : 6.5 

SO2 : 96.0

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1

[3/25/2022, 12;37 PM] K.V: Cause for this young male recurrent DKA ? 

1)Usually it's either non -compliance especially in teenage group ,where they often deny non compliance to medications.

2)Storage of insulin is again one important factor and insulin should be clear without any precipitants/sediments.

3) Lipodystrophy at injection site , will cause irregular absorption of insulin.

So he should avoid taking insulin always at same place

4) Infections

5) Regular follow up and adjustment of doses and strict lifestyle modifications.

Counselling patient and his family is utmost important .

This patient almost died on first admission where he had fulminant hepatic failure (? MISC/post covid ) and was diagnosed as type 1 DM back then .

Again had another admission for DKA.

This is his third admission for another attack of DKA .

Its very difficult to manage a young boy with type 1 DM sir . He has to take insulin 3 times daily ,which would be simple for us to prescribe . But it's difficult in patient perspective . They often ask us for OHA .

I think he would benefit from longer acting insulins sir glargine / degludec. But main problem is again cost .

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375701/

[3/25/2022, 12:39 PM] RB: Is cost the only problem? 

What is the efficacy of glargine or degludec in a head to head comparison with cheaper insulins? 

I feel it's our failure of community medicine

[3/25/2022, 12:40 PM] K.V: Not just cost sir. It ll reduce number of pricks and it's easier to take in the night time one dose .

Compliance would be better always

[3/25/2022, 12:46 PM] K.V: A Randomized Clinical Trial of Insulin Glargine and Aspart, Compared to NPH and Regular Insulin in Children with Type 1 Diabetes Mellitus .

P -Forty patients with T1DM were enrolled in this study. During run-in, all subjects were treated with conventional therapy consisting of twice-daily NPH and thrice-daily regular. Following randomization, 20 subjects received Glargine and Aspart and 20 subjects received NPH and Regular insulin.

I - Glargine and aspart vs regular ,NPH insulin .

O -Mean HbA1c was 8.8% and 8.6% at first and 8.4% and 8.2% at the end of study for subjects randomized initially to Glargine and Aspart and for those randomized to NPH and Regular, respectively (P>0.05). Mean fasting blood glucose (FBS) of the subjects randomized initially to Glargine and Aspart was 217±101 mg/dL, with no significant difference to 196±75 mg/dL for those randomized to NPH and Regular (P=0.48). 

The current study showed no significant difference in glycemic control [Glycated hemoglobin (HbA1c) and FBS] and lipid profile (total cholesterol and triglyceride) between two regimes.

So efficacy is same sir. But life would be easier with long acting insulins.

[3/25/2022, 1:22 PM] AS: The end points are irrelevant to this patient?

[3/25/2022, 1:22 PM] AS: You should probably look at incidence of DKA among both groups and see if there is a difference?

[3/25/2022, 1:23 PM] AS: Also maybe show a study (Ideally from India / Asia) studying the clinical characteristics of DKA in Type 1 DM. Triggers, duration of hospital stay and subsequent discharge medication and subsequent follow up?

[3/25/2022, 2:17 PM] RB: @⁨K.V⁩ where is the link to the full paper?

[3/25/2022, 2:22 PM] RB: How would it reduce the number of pricks? 

The number of pricks will be more with glargine and aspart @⁨K.V

Patient will need to take short acting aspart before every meal (thrice) and glargine separately at bed time 

Whereas 

With nph and regular insulin 

Patient will take three pricks only two mixed before breakfast and dinner and one before lunch

[3/25/2022, 2:23 PM] RB: No they are very relevant in terms of comparing usual efficacy of the expensive vs cheaper approach and here amazingly cheaper wins @⁨AS

[3/25/2022, 2:34 PM] AS: May not be here sir.

I think KV's hypothesis is that because the patient is having to take too many injections, adherence may be poor; reducing the number of injections would improve adherence and thus subsequent incidents of DKA. Did I get it right @⁨K.V

[3/25/2022, 2:36 PM] AS: So she probably has to look into this - Does decreasing injections improve adherence and if improved adherence decreases incidences of DKA?

The first step though starts with an honest conversation with the patient

[3/25/2022, 3:18 PM] K.V: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268837/

[3/25/2022, 3:21 PM] K.V: Yes sir my hypothesis is from patient perspective. Its makes huge difference to just take single prick once daily at night . Degludec infact acts for ,48 hrs . Its peakless insulin too .

Because when we discharged him last time ,he has told me it's difficult to take thrice daily and he works outside..so storage of insulin is also a problem

Pateint and his parents both of them asked for OHA . I told it won't be working and he has to strictly take insulin and come for follow up regularly

[3/25/2022, 3:24 PM] AS: Alright. Insightful 👍🏽

[3/25/2022, 3:58 PM] RB: Not insightful. @⁨AS@⁨K.V

Do you mean you can take care of all his insulin requirements with one injection of degludec? Without using short acting aspart thrice? Why? How?

[3/25/2022, 4:19 PM] AS: Of course not sir. She means the short acting insulin is still to be taken but we could reduced the long acting from 2 to 1.

[3/25/2022, 4:19 PM] AS: Also wanted to ask, can we mix Glargine with Regular insulin for the night dose sir?

[3/25/2022, 4:20 PM] AS: Looking forward sir.

[3/25/2022, 4:21 PM] RB: How's that useful to reduce the number of pricks! 

He will end up with four pricks. Please see what I posted earlier

[3/25/2022, 4:21 PM] RB: No that is where regular and NPH score. 

With glargine you need four pricks 

With the cheaper method it is three

[3/25/2022, 4:22 PM] AS: Game over for Glargine then.

Also NPH costs ₹51 per vial and Lantus is ₹700

[3/25/2022, 4:23 PM] AS: I think KV was thinking thay he is taking NPH and Regular separately sir. So 2 + 3 = 5

[3/25/2022, 4:24 PM] RB: Why would she think that way 🤔

[3/25/2022, 4:25 PM] RB: I knew that game over since last ten years but that doesn't prevent their tremendously successful game in corporate stadium (its an orgi to borrow from your dp)

[3/25/2022, 4:26 PM] AS: Probably because NPH has to be taken after a meal and Regular 15 to 30 mins before?

[3/25/2022, 4:27 PM] AS: Lower risk of Hypoglycemia

[3/25/2022, 4:28 PM] AS: https://pubmed.ncbi.nlm.nih.gov/20185733/

Patients using insulin glargine or detemir (n = 5,317) had a higher DKA incidence than individuals using NPH insulin (n = 5,365, 6.6 +/- 0.4 vs. 3.6 +/- 0.3, P < 0.001). The risk for DKA remained significantly different after adjustment for age at diabetes onset, diabetes duration, A1C, insulin dose, sex, and migration background (P = 0.015, odds ratio 1.357 [1.062-1.734]). CONCLUSIONS Despite their long-acting pharmacokinetics, the use of insulin glargine or detemir is not associated with a lower incidence of DKA compared with NPH insulin.

[3/25/2022, 4:29 PM] AS: @⁨K.V⁩ Let us gracefull show ourselves out of the door 😅

[3/25/2022, 4:30 PM] RB: 👏victory for our unaffording patients

[3/25/2022, 4:31 PM] K.V: Yes sir it's 4 pricks . I thought we can mix it at night time . But is it different for degludec sir ? (48 hrs action ) Supposedly he takes degludec. His basal insulin requirement is covered for 48 hours. 

He has to take short acting insulin pre meal . But advantage is , even if he forgets to take one dose of regular insulin at night time ,he wouldn't land up in DKA . As he is not completly insulin deficient .

Supposedly he is using NPH and regular. Its likely that he would forget taking both at night . So more chance of landing up in DKA ?

[3/25/2022, 4:32 PM] K.V: Okay sir😅

[3/25/2022, 4:38 PM] RB: Interesting but then the current evidence doesn't support unless you can generate some

UNIT 4 

Day 3 of admission 

ICU BED 6 

S: 

C/o vomitings subsided , c/o SOB subsided 

O: 

Pt is c/c/c 

Vitals : 

Temp: 99.4 f

HR: 78 bpm

RR : 20cpm

BP : 130/90 mm hg

Spo2: 99 @ RA

GRBS :

25/3/22

10 am - 119 HAI @ 5 ml / hr

11am - 190 HAI @ 5 ml/ hr

12 pm - 239 HAI @ 5 ml/ hr

1pm-166. HAI @ 5 ml/hr

2pm - 143. HAI @ 5 ml / hr

5pm - 74. HAI @ 5ml / hr ( D5 @ 100 ml / hr)  

6 pm - 258 HAI @ 5ml/ hr 

8pm - 202 HAI @ 5 ml / hr

10 pm - 229 HAI @ 5 ml/ hr

26/3/22

12 am - 190 HAI @ 5 ml/ hr

4 am - 180 HAI @ 5 ml/hr

6 am -264 HAI @ 5 ml/ hr

8 am 291 HAI @ 5 ml / hr

10am - 256 HAI @ 5 ml/ hr

A : Diabetic ketoacidosis with k/c/o type 1 DM, ? MISC post COVID ( July 2021) 

P: 

IVF - NS, RL @ 100ml / hr

Inj. HUMAN ACTRAPID 40U in 39ml NS @ 5 ml /hr 

Nill by mouth 

Inj. PANTOP 40 mg IV / OD 

Inj. Zofer 4mg IV /TID 

INJ. NEOMOL 1 gm IV /SOS ( if temp > 101 F)  

Tab. DOLO 650 mg PO/ TID

Inj. 5% dextrose 50 ml / hr ( if grbs< 250) 

Investigations : 

ABG : 

25/03/22. 26 / 03/22

pH : 7.10. pH : 7.3 

 pCO2 : 6.0. pCO2 : 26.8 

HCO3 : 1.8. HCO3 : 13.9 

S HCO3 : 6.5. S HCO3 : 16.7

SO2 : 96.0. SO2 : 96. 0

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1

UNIT 4 

Day 5 of admission 

ICU BED 6 

S: 

C/o vomitings subsided , c/o SOB subsided 

O: 

Pt is c/c/c 

Vitals : 

Temp: 99.4 f

HR: 78 bpm

RR : 20cpm

BP : 120/80 mm hg

Spo2: 99 @ RA

GRBS :

27/03/22

10 am - 263--- 26U NPH + 26 HAI 

12 pm - 156

1pm-69 --- 10 U HAI

3pm - 177

8pm - 249 ---10 U NPH + 10 HAI 

10 pm - 141

20/03/22

8 am - 365 ---15 NPH + 10 U HAI

A : Diabetic ketoacidosis secondary to ? Inadequate insulin, ? Acute GE 

K/C/O type 1 DM 

H/O acute fulminant hepatitis failure, ? MISC post COVID ( JULY 2021 ) 

P: 

IVF - NS, RL @ 100ml / hr

Inj. HUMAN ACTRAPID 20 U 

inj. NPH 15 U 

GRBS according to 7 point profile 

Before & 2hrs after breakfast 

Before & 2 hrs after lunch 

Before & 2 hrs after dinner 

Inj. PANTOP 40 mg IV / OD 

Inj. Zofer 4mg IV /TID 

INJ. NEOMOL 1 gm IV /SOS ( if temp > 101 F)  

Tab. DOLO 650 mg PO/ TID

Strict I/O charting 

BP, PR monitoring 

https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1