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CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
This patient, an 11-year-old female, presented with diabetic ketoacidosis symptoms including fever, excessive urination and thirst. Laboratory tests found elevated blood sugar, urine ketones and dehydration. She was treated with IV fluids, insulin and monitoring of blood sugar and electrolytes. Her symptoms improved over time and she was discharged with a prescription for long-acting insulin and diet and lifestyle counseling.
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CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
- 2. Name: xyz Age: 11yrs.Sex: female Weight: 19 kg Unit: pediatric-II
- 3. Reason for admission: Referredhere due to high blood sugar. c/o fever x 5days sudden in onset , mild to moderate associated with chills no rigors. c/o excess urination & intake of water x 2days c/o excess thirst & eating of food x 2 days
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- 6. BP: 86/60 mmHgPULSE:92 bpm o/e: Febrile T=100 0F RR = 26 bpm conscious , pallor + signs & symptoms of dehydration CVS: S 1 S 2 + R/S : B/L NVBS + P/A: soft , non tender , no organomegaly CBG: 459 mg/dl 7:30 pm- 312mg/dl 8:30 pm- 192mg/dl
- 7. CNS –Lethargic , Adv: ophthalmology opinion Report: Fundus normal- both eyes
- 8. HAEMATOLOGY: BIOCHEMISTRY: Hb: 13.2g % WBC: 9, 300cells/cumm RBS:454mg/dl(70-150) DLC: N -51% Urea:40mg/dl E -1% SCr:1.3 mg/dl B -0% L -49% ELECTROLYTES: M -0% Na- 133 mmol/L (135-147) PLT -4.39lakhs/cumm K – 4.9 mmol/L (3.5- 5) Cl- 102mmol/L (95-105) Ca- 10.8mg/dl (8.8-10.8)
- 9. MICROBIOLOGY Urineketones +++ Albumin : nil Sugar : 2% Pus cells: 2-3 Epithelial cells: 1-2
- 10. Rx: IVFNS bolus @ 20 ml/ kg over 1 hr. 400ml followed by ½ NS @ 117 ml/ hr Actrapid insulin iv 5 units qid
- 11. TIME THERAPY 1ST HOUR10-20ml/kg iv bolus 0.9% NaCl or RL.insulin drip at 0.05 to 0.1µ/kg/hr 20 ml/kg x 20 kg= 400ml iv bolus 2nd HOUR until DKA resolution 0.45% Saline plus continue insulin drip 5% glucose if blood sugar less than 250mg/dl
- 12. Note thatthe initial iv bolus is considered part of the total fluid allowed in the first 24 hrs and is subtracted before calculating the iv rate. Maintenance (24 hrs)= 100 ml/kg(for the first 10 kg)+ 50 ml/kg (for the 2nd 10 kg) + 25 ml/kg(for all remaining kg) i.e. 1000+(50 x 9)= 1450ml
- 13. i.v rate=85 ml/kg + maintenance – bolus 23 hrs (85 x 19 )+ 1450 – 400 23 =117 ml ½ NS @ 117 ml/ hr for 23 hrs
- 14. BP: 108/60mmHg PULSE:92bpm No fresh complaints o/e : afebrile , conscious, alert , oriented hydration adequate urine: ketones -ve P/A : soft , CNS : NAD Adv: Stop insulin infusion after given SC with monitoring
- 15. IVF- stopped Inj Actrapid 10 units SC qid CBG 8:30 am – 106 mg/ dl 9:30 am -186 mg/dl
- 16. BP: 100/60 mmHgPULSE:96 bpm o/e : No fever conscious , oriented & alert hydration : adequate urine ketones: negative Adv: Dietic advice, CBG monitoring Continue insulin at 10 units SC qid CBG : 3:00 am- 379 mg/ dl 9:30 am – 469 mg.dl 10 pm- high
- 17. BP: 100/68mmHg PULSE:90bpm o/e : afebrile urine sugar +++ ketones -ve Adv : Inj.Actrapid 12 units qid proper diet management CBG: 4 am- 378 mg/dl 4 pm- 337 mg / dl 10 pm- 229 mg/dl
- 18. BP: 100/60 mmHgPULSE:92 bpm Hydration adequate Adv: Diet counselling 10 units qid with CBG monitoring CBG: 5 :30 am -278mg/dl 12 pm- 396 mg/dl 6 pm – 425 mg/dl
- 19. No freshcomplaints No dehydration Adv: Stop Actrapid Start Mixtard insulin 25- 0-15 from tomorrow morning: 15-0-15
- 20. DAY 6 DAY7 CBG 12 am- 441 mg/dl 6 am- 159mg/dl 12pm – 341mg/dl 6pm- 395 mg/dl CBG 1 am- 325mg/dl 7am-235mg/dl 10am-202 mg/dl 6pm-270 mg/dl
- 21. Adv: 15-0-10units Repeat CBG at midnight & afternoon CBG 6 am-74 mg/dl 9:30 am-266mg/dl 2:30pm – 225mg/dl
- 22. Pulse: 100bpm o/e : no fever no dehydration Adv: 25-0-15 units To give midnight snack CBG 1 am-365mg/dl 6 am- 186mg/dl
- 23. Pulse:102 bpm o/e : afebrile no signs & symptoms of respiratory distress Adv: continue 25-0-15 units CBG 12 MN- 358mg/dl 6 am- 93 mg/dl
- 24. Pulse :88 bpm o/e: RS clear CNS: NAD P/A : soft ,nontender CBG 1am-267 mg/dl 7am-389mg/dl 1pm-328mg/dl 7pm-402 mg/dl
- 25. Adv: Dischargeon insulin 25-0-15 units Follow up regularly CBG 12MN- 315mg/dl 6am- 102 mg/dl
- 26. Drug D RF 8/2 9/2 10/2 11/2 12/2 13/2 14/2 IVF NS bolus 400m l iv √ - - - - - - Foll by ½ NS 117 ml/hr iv √ √ sos sos sos sos sos Actra pid insuli n SC QID 10U 10U 12U 10U 10U - Parac etam ol 170 mg supp √ sos sos sos sos sos sos Mixta rd SC BD - - - - - - 25-0 -15
- 27. Drug D RF 15/2 16/2 17/2 18/2 IVF NS bolus - - - - - - - Foll by ½ NS - - - - - - - Actrapi d insulin SC - - - - Paracet amol 170 mg supp sos sos sos sos sos Mixtar d SC BD 15-0- 10 25-0- 15 25-0- 15 25-0- 15
- 28. Subjective fever polyuria polydipsia &polyphagia Objective Urine ketones +++ Urine sugar : 2% Elevated RBS: 454mg/dl (70-150)
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- 30. Fluid &electrolyte balance Correction of hyperglycemia To prevent hypokalemia & cerebral edema
- 31. IV Fluids Insulin preparations: Rapid acting- Lispro , Aspart , Glulisine Intermediate acting – NPH Long acting – Glargine , Detemir
- 32. Sign &symptoms of dehydration was reduced by Day 2 Urine ketones were absent by Day 2
- 33. Blood Glucoselevels Body weight Electrolytes Urine ketone & urine sugar Symptoms of hyperglycemia Symptoms of cerebral edema Diet habits
- 34. Bicarbonate level notmonitored
- 35. ABOUT THEDISEASE sign & symptoms complications ABOUT THE MEDICATION purpose & dose importance of medication adherence possible adverse effects
- 36. ABOUT LIFESTYLEMODIFICATION Diet Exercise