Diabetic Ketoacidosis case study in 1 hospital at Perak

1. CASE STUDY:
DIABETIC KETOACIDOSIS

2. INTRODUCTION
• Definition
• Pathophysiology
CASE PRESENTATION
• Patient’s Info
• History
• Presentation
• Vital Sign
INVESTIGATION
• Blood Investigation
• Radiology
MANAGEMENT
• Principal
• Intervention @ ED
01
03
02
04
TABLE OF CONTENTS

3. INTRODUCTION
01

4. INTRODUCTION
 Diabetic ketoacidosis (DKA) is among the most serious acute complications of T2DM.
 It has a high mortality rate if unrecognized. The overall mortality is <1%, but a
mortality rate of>5% in the elderly has been reported.
 Mortality in patients with DKA is frequently related to the underlying aetiological
precipitant rather than the metabolic sequelae of hyperglycemia or ketoacidosis.
 DKA is mainly characterized by hyperglycemia, acidosis-producing derangements, and
dehydration.
 Infection, disruption of insulin, and the onset of diabetes are some of the common
causes of DKA.
KKM Clinical Practice Guide MANAGEMENT OF TYPE 2 DIABETES MELLITUS (2020)

5. PATHOPHYSIOLOGY
Insulin Deficiency
Breakdown of fat
& amino acid
Osmotic diuresis
causes
dehydration &
Electrolyte
disturbance
Acid buildup
(Ketones)
LIVER
SHOCK
KETONE
INSULIN
BLOOD
Blood becomes acidic
(Metabolic Acidosis)
BRAIN
It can cause acute
cerebral edema
(1%)

6. CASE
PRESENTATION
02

7.  47-year-old
 Malay
 Female
 Housewives
 Height: 155cm / Weight: 63kg
PATIENT’S INFO
YOURLOGO

8. HISTORY/MEDICINE
-Type 2 Diabetes
• Tab Metformin 500mg BD
• S/C Mixtard 30 unit BD
• Defaulted insulin injection & follow-up for 1/12
-Dyslipidemia
-Hypertension
-No other past history of medical/surgical
-No known food or drug allergies

9.  Generalized Body Weakness x 2/7
 Palpitation
 Fever
 Right Breast Swelling
COMPLAINT
YOURLOGO

10. EXAMINATION
RESPONSE
• Alert & Conscious, GCS 15/15
AIRWAYS
• Open, patent & maintainable, Not tachypneic
BREATHING
• RR: 19/min
• Lungs: Equal air entry & clear
• The breast appears to be swelling but no visible pus
CIRCULATION
• Skin pink, not mottled, mild dehydrated looking
• CVS: Dual Rhythm No Murmur
• Pulse: Tachycardia, regular, strong, warm
• Abdomen: Soft, no tender & guarding
• No pedal edema

11. 185/95
MMHG
BLOOD PRESSURE
136
BEATS/MIN
PULSE RATE
19
BREATH/MIN
RESPIRATORY RATE
VITAL SIGN
100%
under RA
SPO2
38.0oC
19.3
mmol/L
Glucometer/DXT
Temperature

12. INVESTIGATION
03

13. INVESTIGATION
BLOOD/URINE INVESTIGATION RADIOLOGY & ECG
• Chest X-Ray
• Electrocardiogram
• Blood Ketone
• Full Blood Count
• Venous Blood Gases
• Renal Profile
• Urine FEME

14. UFEME
• Glucose 4+
• Ketones 3+
• Nitrite –ve
• Leucocyte -ve
FBC
• WBC: 24.4 10³ /uL
• Hb: 11.0 g/dL
• Hct: 32.6%
DXT
• 19.3 mmol/L
RP
• Urea 7.4 mmol/L
• Sodium 124 mmol/L
• Potassium 4.8 mmol/L
• Chloride of 95 mmol/L
• Creatinine 142 μmol/L
Blood Ketone
• High Index (HI)
VBG
• pH 7.19
• pCO2 21.6 mmHg
• HCO3 10.5 mmol/L
BLOOD/URINE INVESTIGATION

15. ELECTROCARDIOGRAM
Basic
• Sinus
• Rhythm: Regular
• Rate: 120/min
PQRST
• Present P Wave
• PR Interval: 0.12 sec
• QRS Complex: 0.04 sec
• T Inverted over aVR &
V1 (Normal)
Interpretation
Sinus Tachycardia

16. X-RAY (CHEST)
Finding
• AP View
• No abnormalities
• No consolidation
visible
• No cardiomegaly
• No
pneumothorax
• Gastric bubble
seen
• X-Ray Clear

17. ADDITIONAL TEST
Serum
Osmolality
Formula : (2 x serum
[Na]) + [glucose] + [urea]
(all in mmol/L)
Or laboratory measured value
(2 x [124]) + [19.3] + [7.4] =
274.7
Normal range 275-295 mosmol/kg
Anion Gap
Formula
([Na+] + [K+]) − ([Cl-] + [HCO −])
(124 + 4.8) – (95 + 10.5) =
23.3
Normal range 8 – 16 mmol/L

18. —PRECIPITATING FACTORS
Precipitating
Factors
• Infection
• Missed insulin therapy
• ACS
• CVA
• Surgery
This Patient
• Missed insulin therapy
• Fever & Increased WBC
(Probable Infection)

19. DIAGNOSIS
This patient
• Blood glucose 19.3mmol/L
• Blood Ketone High Index
• Urine ketones 3+
• Venous pH 7.19 & Bicarbonate 10.5 mmol/L
Criteria for
diabetic
ketoacidosis
• Capillary blood glucose >11 mmol/L
• Capillary ketones >3 mmol/L or urine ketones ≥2+
• Venous pH <7.3 and/or bicarbonate <15 mmol/L
• Diabetic Ketoacidosis
Diagnosis

20. MANAGEMENT
04

21. o Restoration of patient’s hydration (Normal
Saline/Hartman)
o Insulin administration
o Constant monitoring of Vital Signs & DXT (hourly)
o Constant urine output monitoring
o Keep patient NBM with the administration of
Pantoprazole/Nexium
o Repeat investigation per management to Ensure
clinical & biochemical parameters are continuing to
improve or are normal
o Prevent hypokalemia by KCL administration with fluid
given
BASIC PRINCIPAL

22. MANAGEMENT GIVEN @ ED
 Reassure patient
 Let the patient rest in bed comfortably
 IV Access (Large Bore) x2
 Constant V/Sign & Cardiac Monitoring
 ECG & Portable CXR
 IVD N/Saline bolus over 1 H
 Tab PCM 1g
 S/C Actrapid 6 unit
 IV Pantoprazole 40mg
 CBD inserted

23.  Start DKA Regime:
1. -IVD N/Saline 1L over 1 Hour (Post Mx DXT:19.0 mmol/L)
2. -IVD N/Saline 1L over 2 Hour (Post Mx DXT: 18.5 mmol/L)
3. -IVD N/Saline 1L over 4 Hour
 IVI Actrapid 50 unit in 50ml N/Saline run 6ml/H
 Check DXT hourly
 IVD N/Saline 500ml with KCL 1g maintenance
 Refer medical team for further management
 IV Cefuroxime 1.5g stat
 Admit to HDU

24. PRECAUTION
 IF DXT < 13.5, START ON NSD5% MAINTENANCE
 IF K < 3, FOR FAST CORRECT
 IF K 3-3.4,+1.5GKCL IN EACH PINT OF DRIP
 IF K 3.5-4.0,+1G KCL IN EACG PINT OF DRIP

25. AIM OF TREATMENT
1. Rate of fall Of Ketone is at 0.5mmol/L/Hr
2. HCO3 rise at 3 mmol/L/Hr
3. Blood glucose falls 3 mmol/L/Hr
4. Maintain serum potassium at a normal range
5. Ensure clinical and biochemical parameters improving
6. Continue IV fluid replacement/maintenance
7. Avoid hypoglycemic
8. Assess for complications of treatment (eg: Fluid Overload, Hypoglycemia, Cerebral
Edema)
9. Treat precipitating factors if necessary

28. THANK YOU
FOR
LISTENING
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