Case study of DKA taken in a hospital in Malaysia

1. Case Study:
DIABETIC
KETOACIDOSIS
MHBS

2. 03
01 02
04
Table of contents
Introduction
• Definition
• Pathophysiology
Case Presentation
• Patient’s Info
• History
• Presentation
• Vital Sign
Investigation
• Blood Investigation
• Radiology
Management
• Principal
• Intervention @ ED

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. Patient’s Info
 47-year-old
 Malay
 Female
 Housewives
 Height: 155cm / Weight: 63kg
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. Complaint
 Generalized Body Weakness x
2/7
 Palpitation
 Fever
 Right Breast Swelling
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
136
beats/min
19
breath/min
Vital Sign
Blood Pressure Pulse Rate Respiratory Rate
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. Aim Of Treatment:
6. Ensure clinical and biochemical parameters improving
7. Continue IV fluid replacement/maintenance
8. Avoid hypoglycemic
9. Assess for complications of treatment (eg: Fluid Overload, Hypoglycemia,
Cerebral Edema)
10. Treat precipitating factors if necessary

28. THANK
YOU FOR
LISTENING
Any Question?