1.  A 55 year male patient was brought by
relatives to the ESR with c/o pain and
swelling over lt foot extending upto below
knee.Pt also c/o abdominal pain and
drowsiness since two days.
 O/E:- P:120 bpm, BP:-100/60 mmHg, RR:-
30cpm, Per abdomen exam reveals
tenderness.

3.  General and systemic including airway exam.
 Routine blood investigations:
 Hb:10gm%, CBC: 20200/cu.mm, RFTs &
LFTs: WNL, RBS: 320mg/dl,
 Serum. electrolytes:- Sr. Na:130mEq/l, Sr. K:
5mEq/l
 Chest Xray: increased BVM, ECG: NSR, Urine
routine microscopy;

4.  Special investigations:
 Serum and urine ketones: ++,
 ABG:- pH:7.25, pO2:90, pCO2:28, Sr
bicarbonate:15, BE:-9, SO2:97%
If a classic triad of DKA i.e hyperglycemia,
ketonemia and metabolic acidosis is
seen,diagnosis

5.  A state of absolute or relative insulin
deficiency aggravated by ensuing
hyperglycemia, dehydration, and acidosis-
producing derangements in intermediary
metabolism, including production of
serum acetone.
 Can occur in both Type I Diabetes and
Type II Diabetes
 In
type II diabetics with insulin
deficiency/dependence
 The presenting symptom for ~ 25% of Type
I Diabetics

7.  Stressful precipitating event that results
in increased catecholamines, cortisol,
glucagon.
 Infection (pneumonia, UTI)
 Alcohol, drugs
 Stroke
 Myocardial Infarction
 Pancreatitis
 Trauma
 Medications (steroids, thiazide diuretics)
 Non-compliance with insulin

8.  Polyuria
 Polydypsia
 Blurred vision
 Nausea/Vomiting
 Abdominal Pain
 Fatigue
 Confusion
 Obtundation

9.  Tachycardia
 Dehydration / hypotension
 Tachypnea / Kussmaul respirations /
respiratory distress
 Abdominal tenderness (may resemble acute
pancreatitis or surgical abdomen)
 Lethargy / obtundation / cerebral edema /
possibly coma

10.  INSULIN
 Administer short-acting insulin: IV (0.1
units/kg) or IM (0.3 units/kg),
 then 0.1 units/kg per hour by continuous IV
infusion;
 Increase 2- to3-fold if no response by 2–4 h.
 If initial serum potassium is < 3.3
meq/l,correct K level while giving insulin to
prevent dangerous hypokalemia.
 Expected fall is 50-100 mg/h
 Transition into SQ when:
A. Plasma glucose is less than 250 mg/dl
B. DKA has resolved (usually less than 12 hs)
C. Patient is tolerating PO

11. FLUID
1. Deficit is around 6-8 L – need NOT to replace
all of it with IV fluid
 Replace fluids: 2–3 L of 0.9% saline over first
1–3 h (10–15 mL/kg per hour);
 Subsequently 0.45% saline at 150–300mL/h;
 Change to 5% glucose and 0.45% saline at
100–200 mL/h when plasma glucose reaches
250 mg/dL (14 mmol/L).
 Watch BP, pulse, BUN/creatinine and urinary
output.
 Use plasma expanders/blood if in shock and
does not respond quickly to saline.

12. ELECTROLYTES
1. The critical is K
2. There is always a deficit, but blood levels
may be low, normal or high
3. Frequent EKG and serum levels are
mandatory
4. Initially IV may be the only way to
administer K but remember that once PO is
re-established, K can be given orally.
 Factors reducing serum K+
 􀁺 Rehydration → ↑ urinary secretion of K+
 􀁺 Insulin administration moves K+ from
extracellular to intracellular.

13. Replace K+:
 10 meq/h when plasma
K+ < 5.5 meq/L, ECG
normal, urine flow and SERUM K
LOW (<3.5)
Rate hour
40 Meq
Normal (3.5-5.0) 20 Meq
normal Cr. Normal, pH <7.0 or
EKG changes
40 Meq
High (>5.0) Hold until level
 40–80 meq/h when High (>5.0) pH < 7.0
normal
10-20 meq
or EKG changes
plasma K+ < 3.5 meq/L
or if bicarbonate is
given.

14. BICARBONATE
1. Usually NOT necessary
2. It may even be dangerous and
precipitate hypokalemia, cerebral
acidosis and cardiac dysfunction
3. For very severe acidosis (pH <6.9) use
very small amounts enough to elevate
pH to 7.0

15. PHOSPHATE AND OTHER ISSUES
Supplementation only advised if Serum
phosphate conc <1.0mg/dl or in the
presence of anemia, cardiac
dysfunction.
If needed, 20-30 mEq/l potassium
phosphate can be given.
Broad spectrum antibiotic coverage is
required.

16.  Measure capillary glucose every 1–2 h;
 electrolytes (especially K+, bicarbonate, phosphate) &
anion gap every 4 h for first 24 h.
 Monitor BP, pulse, respirations, mental status, fluid intake
and output every 1–4 h.
 Assess patient:
 What precipitated the episode (noncompliance, infection,
trauma, infarction, cocaine)?
 Initiate appropriate workup for precipitating event
(cultures, CXR, ECG).
 Continue above until patient is stable, glucose goal is 150–
250 mg/dL, and acidosis is resolved.
 Insulin infusion may be decreased to 0.05–0.1 units/kg/hr.

17.  Cerebral edema  Pulmonary Edema
First 24hrs and Hypoxemia
 Mental status changes
 Tx: Mannitol
 Iatrogenic
 May require intubation
hypoglycemia and
with hyperventilation hypokalemia
 Shock
 If not improving with
fluids r/o MI
 Vascular
thrombosis
 Severe dehydration
 Cerebral vessels
 Occurs hours to days
after DKA

18.  With a central line already in situ, patient is
taken inside the O.T. after checking
starvation and high risk consent.
 Adequate amount of crossmatched blood is
kept ready.
 The standard monitors attached. HGT,CVP
and urine output monitoring is essential.
 IV fluid is attached.

19.  Low dose unilateral sub arachnoid block can
be given using 0.5%(H) Inj.Bupivacaine and
Inj. Fentanyl as additive making a total
volume of 1.2-1.4cc.
 Excellent analgesia.no need to use NSAIDS or
opiods intra op.
 Hypoglycemia & hyperglycemic coma can be
detected early.
 Avoidance of ETT & resultant infection.

20.  Disadvantages:
 Inadvertant higher level of block can result
in hypotension complicated by autonomic
neuropathy in DM.
 Sympathetic blockade can impair control of
insulin secretion.

21.  Femorosciatic nerve block can be given which
helps prevent hypotension and also provides
superior intra and post op analgesia

22.  Epidural anaesthesia either single shot or
catheter in situ can be used to avoid
hypotension and also for post op pain relief.
 Disadvantage includes risks of infection and
vascular damage.

23.  For small ulcers confined to foot, ankle block
using Inj. Bupivacaine and Inj Lignocaine can
be given.

24. Aspiration prophylaxis is given with antacid
and antiemetic.
 Rapid sequence induction should be done in
case of inadequate starvation or autonomic
neuropathy(gastroparesis).
 Muscle relaxant: Rocuronium should be used
instead of Sch i/c/o hyperkalemia
 After induction, Inj.midazolam and
opiod(preferably fentanyl) is given in titrated
doses for analgesia and sedation.

25.  Maintenance: oxygen & nitrous oxide and
sevoflurane or Isoflurane.
 Reversal:routine reversal
 Extubation: after adequate recovery of
airway reflexes.
 Post op monitoring: blood sugar level,serum
and urine ketones, serum electrolytes