James Band is a 17 year-old young man (previously well) who presents with 8 kg unintentional weight loss, polyuria and polydipsia. He is oriented but drowsy, BP 100/60 HR 88 supine, 80/p, HR 110 standing. Labs: glucose 24 mmol/l, Na 130, K 3.5, Cl 95, HCO3 8, positive serum ketones. The ER doctor has already given him 1 litre of normal saline and 8 units regular insulin i.v. push, and another 8 units iv over the past hour.
What is your biggest concern?
When would you consider giving sodium bicarbonate?
What would you monitor to ensure insulin dose is working (glucose, serum bicarbonate, serum anion gap, serum ketones)? What is your rationale?