Charisma, an 11-year-old girl, was brought to the emergency room severely dehydrated and in diabetic ketoacidosis. Her blood glucose was 623 mg/dL and blood tests showed metabolic acidosis. She was admitted to the ICU for intravenous rehydration, bicarbonate therapy to correct acidosis, potassium replacement, and insulin infusion to lower her blood glucose levels. Her treatment involved careful monitoring, gradual rehydration and correction of electrolyte imbalances, transitioning from IV to subcutaneous insulin, and treatment of any underlying infections. The document outlines the management steps and monitoring for treating diabetic ketoacidosis.

1. DIABETIC KETOACIDOSIS
-Management
 Dr.Abhijeet

2.  Charisma a 11 yr old girl brought to casualty
with c/o drowsiness, abdominal pain, Fast
breathing ,nausea & vomiting with weight
loss 3-4 kg in 2 weeks.
 She had h/o high grade fever 4-5 days back &
treated with Antibiotics in other hospital.
 All blood investigations were done there
except GRBS.

3.  O/E : She was severely dehydrated with
acidotic breathing /tachypnoea & in state of
altered consiousness.

4.  Monitoring and Investigations:
-Moderate-severe DKA- Admit in ICU.
-Hrly HR,RR,BP, Spo2, GCS
-Monitor for warning signs of cerebral edema
: Headache, bradycardia, recurrent vomiting, altered
sensorium, CN palsies, abnormal pupillary response.

5.  LAB TESTS:
-Hrly GRBS, Blood gas Q4H, Sr electrolytes-Q4H,
-Blood urea, creat.-Q12H
On admission:Charisma’s GRBS was 623mg/dl,
ABG: pH-6.3, HcO3-6.7

6.  MANAGEMENT:
1. IV Rehydration:
-Check for level of dehydration
-If shock signs +, give Bolus NS 0.9% 10 ml/kg over 30 min.
-Initial fluid boluses are not required if no signs of shock.
Maintainence Fluid:
<10kg - 100ml/kg/day
10-20kg- 1000ml + 50ml/kg for each kg> 10kg
>20 kg - 1500ml + 25ml/kg for each kg >20 kg

7. Eg : for 35 kg child
Maintainence fluid :
(85ml x 35kg) + 1875 ml– Bolus /23=ml/H
=119 ml/Hr
Max fluid over 24 hr -4L/m2
-Underhydration is safer than overhydration.

8. -Start rehydration with NS over 48 hrs.
-Strict fluid balance charting every few hrs.
2. Acidosis correction & Bicarbonate therapy:
-DKA patients have wide Anion gap metabolic acidosis
d/t excess of Ketones & Lactate
-Use of Bicarb therapy is contravercial as it may cause
Paradoxical CNs acidosis, Hypokalemia, Increased Na
load & sudden rise in Sr osmolality.

9.  Indications of Bicarb Therapy-
-PH<7
-Refractory shock
-Life threatening hyperkalemia
 HCO3 required in mmol = 0.3 X Wt.in KgX
Base deficit
Give half of calculated bicarb. Over 4 Hrs by
slow infusion then reassess Blood gas, cease
when Ph<7

10.  Potassium replacement:
- DKA Patients have profound total body potassium
deficit d/t polyurea . Hypokalemia worsens with
hydration & Insulin.
- K+ Replacement should begin prior to commencing the
insulin infusion, after initial fluid bolus.
- Start K+ at the rate of 5meq/kg/day.
reassess K+ every 2 Hrs for 1st 6 Hrs then every 4 Hrly.

11. -Aim to maintain K+ > 4-4.5 m eq/L.
 Insulin infusion:
- Start after correction of shock.
- Start at 0.05-0.1 units/kg/hr.
- Aim to fall Blood glucose at 100mg/dl/hr.
- Titration of Insulin:
- Adjust insulin infusion rate to keep BSL between 100-
200mg/dl.

12. - Decrease insulin infusion rate by 50% if BSL fall is >
100mg/dl/hr
- Increase insulin rate by 50% if BSL fall is
<100mg/dl/hr
- Change IVF to ½ NS + D5% when BSL falls below
300mg/dl.

13.  Cerebral edema
- It is the sudden unexpected complication of therapy of
DKA which occurs during 1st 24 Hrs of t/t, usually when
metabolic parameters are normalizing.
- Monitor GCS.
- Mannitol 1-1.5 gm/kg by rapid IV infusion aiming to
rise Sr osmolality by 5-10 m osm/kg & decrease
cerebral edema.

14.  Treatment of precipitating infections if present.
-Urine & Blood c/s done to rule out any focus of
infection.
- Start impirical antibiotics if Raised blood Total
counts persisting or active focus of infection
present.

15.  Oral feeds-
- Kept NPO till metabolically stable, i.e(BSL<200, pH>
7.3, HCO3>15mmol/L).
 Stopping of IV Insulin:
- When child is alert & Metabolically stableMost
convinient time to chance to SC insulin is just before
meals.

16.  Suggested Schedule:
- SC insulin 30 min before meal meal + insulin
infusionstop infusion 90 min after SC dose.
- Usual total daily dose is 1 U/Kg/day.
- May require modification as per BSL values.

17. - If the metabolic state is not attained correctly, The
‘SEVENTH’S SCALE insulin regime can be started :
Short acting insulin given Q6H with
2/7th total daily dose given before breakfast,
2/7th before Lunch,
2/7th before evening food &
1/7th without food at midnight

18.  If child;s metabolic state is normal, proceed directly
to ‘Combined insulin regimen’:
- Combination of Long+ Short acting insulin given
BD, 30 min prior to morning & evening meals i.e.
2/3rd of total daily insulin in morning &
1/3rd prior to Dinner.
- BSL may be checked ½ Hr prior & 2 Hrs after each
meals.

19. THANK YOU !