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.

2. Name: xyz
Age: 11yrs. Sex: female
Weight: 19 kg Unit: pediatric-II

3. Reason for admission:
Referred here 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

4. PMHX: NS
Allergy: NKA

5. DIABETIC KETOACIDOSIS

6. BP: 86/60 mmHg PULSE: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: 13.2 g %
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
 Urine ketones +++
Albumin : nil
Sugar : 2%
Pus cells: 2-3
Epithelial cells: 1-2

10.  Rx:
 IVF NS 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 HOUR 10-20ml/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 that the 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 mmHg PULSE: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:90 bpm
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 mmHg PULSE: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 fresh complaints
 No dehydration
 Adv: Stop Actrapid
Start Mixtard insulin 25- 0-15 from
tomorrow
morning: 15-0-15

20. DAY 6 DAY 7
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: 15-0-10 units
 Repeat CBG at midnight & afternoon
CBG
6 am-74 mg/dl
9:30 am-266mg/dl
2:30pm – 225mg/dl

22.  Pulse: 100 bpm
 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: Discharge on insulin 25-0-15 units
 Follow up regularly
CBG
12MN- 315mg/dl
6am- 102 mg/dl

26. Drug D R F 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 R F 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)

29. DIABETIC
KETOACIDOSIS

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 Glucose levels
 Body weight
 Electrolytes
 Urine ketone & urine sugar
 Symptoms of hyperglycemia
 Symptoms of cerebral edema
 Diet habits

34. Bicarbonate level not monitored

35.  ABOUT THE DISEASE
sign & symptoms
complications
 ABOUT THE MEDICATION
purpose & dose
importance of medication adherence
possible adverse effects

36.  ABOUT LIFESTYLE MODIFICATION
 Diet
 Exercise