Case study on diabetic ketoacidosis

1. TYPE-II DIABETES MELLITUS WITH
DIABETIC KETOACIDOSIS

2.  DEMOGRPHIC DETAILS:
• Name : xyz Age : 60 D.O.A : 21/04/17
• SEX : M IP.No.13108 D.O.D :24/04/17
 REASONS FOR ADMISSION:
• C/o vomitings ; 4-5 episodes
• Loose motions _ since 4 days
 History of present illness :
No similar complaints in past
 Past medication history :
• k/c/o T2 DM _since 4 years
(Stopped insulin 4 days back )

3.  Personal habits : alcohlic+ ,smoker +
General examination :
• O/e pt c/c TEMP : afebrile
Systemic Examination
• BP : 90/60 mmhg PR : 65 / min
• Resp : BAE+ CVS : S1+S2+
• GRBS : >600mg/dl
• PROVISIONAL DIAGNOSIS : T2DM with DKA ?

4.  Rx : IVF 1pint NS
Inj.Ondonsetron IV
• LABORATORY INVESTIGATIONS
 Urine ketones : ++
 Sugars : ++
 FBS : 290mg/dl

 FINAL DIAGNOSIS : TYPE 2 DIABETES MELLITUS
WITH
DIABETIC KETOACIDOSIS

5.  Day 1 :
Rx
 IV NS 2 pints over 30 min - 2 pints over 1 hr -300 ml over 1hr
 INJ.REGULAR INSULIN 8 U /IV/STAT
 INJ.REGULAR INSULIN 40U IN 1PINT NS @30drops/min till GRBS
250mg/dl
 INJ.CEFTRIAXONE 1g / IV / OD
 INJ.PANTOPRAZOLE 40mg / IV / OD
 INJ.ONDONSETRON 4mg / IV / OD
 Advice : monitor GRBS regularly

6.  Day 2 : O/e pt c/c
• BP : 100/60mmhg PR : 70/min cvs : s1+s2+
• C/o Dry tongue ,burning epigastrium
• GRBS : 220mg/dl
 Rx
 IVF 4 PINTS NS
 1 PINT RL
 INJ.REG INSULIN 10U /SC /TID
 SYP.SUCRALFATE 10ml/PO/TID
 TAB .MVT PO/OD
 INJ.NEUROKIND 1amp /IM /OD
 INJ.CEFTRIAXONE 1g/ IV /BD
 INJ.PANTAPRAZOLE 40mg /IV / OD

7.  Day 3 :
• O/e pt c/c
• BP : 120/90mmhg PR : 90/min
• Resp.: BAE+ CVS : s1+s2+
 GRBS : 206mg/dl
 Rx
 CST
 INJ.REGULAR INSULIN 12U /SC/TID
 INJ.METOCLOPRAMIDE 1amp/IV/ BD

8.  DIABETIC KETOACIDOSIS : It is an acute, major, life-threatening
complication of diabetes. DKA mainly occurs in patients with type 1 diabetes, but
it is not uncommon in some patients with type 2 diabetes
 DKA is a state of absolute or relative insulin deficiency aggravated by ensuing
hyperglycemia, dehydration, and acidosis-producing derangements in
intermediary metabolism. The most common causes are disruption of insulin
treatment, and new onset of diabetes.
 Biochemically, DKA is defined as an increase in the serum concentration of
ketones greater than 5 mEq/L, a blood glucose level greater than 250 mg/dL
(although it is usually much higher), and a blood (usually arterial) pH less than
7.3. Ketonemia and ketonuria are characteristic, as is a serum bicarbonate level of
18 mEq/L or less (less than 5 mEq/L is indicative of severe DKA).

9.  Goals of treatment :
 Correction of fluid loss with intravenous fluids
• (Fluid loss averages approximately 6–9 L in DKA. The goal is to replace the
total volume loss within 24–36 hours with 50% of resuscitation fluid being
administered during the first 8–12 hours.)
 Correction of hyperglycemia with insulin
 Correction of electrolyte disturbances, particularly potassium loss
 Correction of acid-base balance
 Treatment of concurrent infection, if present

10.  Standard treatment :
 Initial correction of fluid loss is either by isotonic sodium chloride solution or
by lactated Ringer solution.
 The recommended schedule for restoring fluids is as follows:
 Administer 1-3 L during the first hour.
 Administer 1 L during the second hour.
 Administer 1 L during the following 2 hours
 Administer 1 L every 4 hours, depending on the degree of dehydration and
central venous pressure readings
 After initial stabilization with isotonic saline, switch to half-normal saline at
200-1000 mL/h

11.  Insulin : Initial bolus of regular insulin of 0.1 U/kg followed by continuous
insulin infusion(0.1U/kg/hr) using infusion pump. If plasma glucose does not fall
by at least 10% in the first hour of insulin infusion rate, 0.1 U/kg bolus of insulin
can be given once more while continuing insulin infusion.
 Larger volumes of insulin may be easier in the absence of an IV infusion pump
(eg, 60 U of insulin in 500 mL of isotonic sodium chloride solution at a rate of
50 mL/h).

12. • PHARMACIST INTERVENTION:
 Before starting Insulin therapy, plasma potassium levels must be monitord.
Because sudden insulin administration may lead to hypokalemia and worsen
the situation.
• DRUG INTERACTION :
 ceftioxone should not be given with Ringer lactate.Calcium in ringer solution
precipitates with ceftriaxone in blood and may lead to kidney damage
 GOALS ACHEIVED :
 Patient glucose levles are under control
 Fluid loss is corrected
 Symptoms subcided

13. DISCHARGE MEDICATION :
 INJ.HUMAN MIXTARD 30/70
 20 units------------10 units
 Tab .METFORMIN 500mg BD /PO
 TAB .MVT OD/PO
 REVIEW AFTER 10 DAYS

14.  PATIENT COUNSELLING :
 Take insulin 30min before meals.Change the site of administration for every
time.
 Regularly monitor blood glucose levels
 Do not stop insulin unless doctor advice
 If you get hypoglycemic symptoms on treatment , such as tremors ,palpitations
,sweating ,immediately take some glucose rich food ( sugar water/chocolate)