Using metabolic parameters to inform emergency care referral in a patient with a hyperglycemic induced acute kidney...

To describe the clinical reasoning and use of the American Diabetes Association (ADA) blood glucose and exercise guidelines in the face of an emerging acute glycemic crisis for a patient with type 2 diabetes mellitus receiving physical therapy for chronic ankle instability and fibromyalgia.

Assessment of the patient's baseline blood glucose and ketone urinalysis revealed hyperglycemia and ketonuria, respectively. Shortly after testing, the patient became nauseous and vomited. This prompted assessment of her end-tidal carbon dioxide via nasal capnography to screen for diabetic keto-acidosis. Evidence of Kussmaul breathing, tachypnea, and hypocapnia in conjunction with hyperglycemia and ketonuria, as well as symptoms of nausea and signs of vomiting prompted a referral to the emergency department.

The patient was admitted to the hospital for five days with a diagnosis of acute kidney injury. It was determined that the acute kidney injury was caused by hyperglycemia in combination with impaired kidney function and an exacerbation of her congestive heart failure, all of which are known risk factors for acute kidney injuries in patients with diabetes mellitus.

Compliance with the ADA blood glucose exercise guidelines allowed for early recognition of metabolic dysfunction prior to the onset of symptoms. Failure to have complied with the ADA blood glucose exercise guidelines may have resulted in the physical therapist administering therapeutic exercise that likely would have contributed to a worse prognosis.