case presentation of diabetic keto acidosis ethology, investigations and treatment bicarbonate therapy protocol

1. Case Presentation # 1
Dr. Prasenjit Gogoi MBBS, MEM
Attending Consultant,
Emergency Medicine
Apollo Hospitals Guwahati

2. Patient profile
• Name – Ms Parbina Begum
• Age – 25 years
• Sex – Female
• Religion – Islam
• Marital status – Unmarried
• Region – Barpeta, Assam
• Date of admission – 31/01/2021

3. Chief Complaints
• Shortness of breath
• Restlessness
2 days

4. • History of present illness
Patient had H/O loose stools for
past 7 days for which she was admitted in local
hospital in Barpeta. During the course of
treatment patient started developing shortness
of breath and became restless for past 2 days.
There is no H/O fever, pain abdomen, decreased
urine output etc.
*No discharge/referral document was present as patient
relatives had taken DAMA.

5. • History of past illness
Type 1 DM x 10 years on Insulin
(prescription not available)
No surgical history
• Personal history
Diet – Non vegetarian
Non smoker/ Non alcoholic
Allergy – not known
Marital status – unmarried
LMP – 10/01/2021
• Family history
• Socio-economic history – lower middle class

6. Vitals
• Pulse – 116 bpm
• Blood pressure – 110/70 mmHg
• Resp. rate – 22 / min
• SpO2 – 100% in room air
• Temp – 98o F
• CBG – 539 mg/dL

7. General examination
• Patient was conscious, restless & disoriented,
ill looking, laying supine on trolley, IV cannula
in right hand.
• Height and weight assessment could not be
done as patient was unable to stand.
• Pallor +, Oedema +, Dehydration +
• Icterus, lymphodema, cyanosis, clubbing - Nil

8. Systemic Examination
• Chest – B/L air entry equal,
Kussmaul breathing +
• CVS – S1S2M0
• Per Abdomen – soft, non tender,
bowel sound +, no surgical scar
• CNS – GCS E4V4M6
No focal neuro deficit

9. Differential Diagnosis
• Acute gastroenteritis with dehydration
• Diabetic ketoacidosis
• Hyperosmolar hyperglycemic state
• Acute pancreatitis
• Renal failure
• Sepsis
• Ingestion – salicylates, ethylene glycol,
methanol
• Hysterical hyperventilation

10. Point-Of-Care Investigations
ABG
• pH – 6.8
• pCO2 – 12.9
• pO2 – 152
• HCO3 – 1.9
• Na+ - 131 mmol/L
• K+ - 4.8 mmol/L
• Urine Dipstick –
ketones positive
• ECG – Normal sinus
rhythm

11. Diabetic Keto Acidosis

12. Management
Drug Dose Route
IVF Normal Saline 500 ml bolus followed by 125 ml/hr
infusion
IV
Insulin H. Actrapid 6 ml/hr infusion IV
NaHCO3 50 ml bolus followed by
15 ml/hr infusion
IV
Meropenem 1 gm IV
Teicoplanin 400 mg IV
Pantoprazole 40 mg IV
Ondansetron 4 mg IV
Procedure
IV Cannulation + Foleys catheterisation

13. Investigations on 31/01/2021
Hb 6.7 gm/dL
TC 18320
Platelets 3.1
ESR 50
CRP 7.7
Procal 0.8
Creatinine 1.37 mg/dL
Urea 40 mg/dL
Na 135 mmol/L
K 3.8 mmol/L
Mg 2.0
Ca 7.3
Bil 0.59 mg/dL
SGOT 93
SGPT 86
GGT 271
T. Protein 6.5
Alb/Glob 3.0
P.Time 13.2
HbA1C 11.2%
CXR-PAV USG(W/A)
Haziness in both lung fields Hepatomegaly + minimal
ascitis and B/L pleural effusion

14. Further management
• Patient was shifted to ICU
• Infusion NaHCO3 was tapered and stopped on
01/02/2021
• Infusion H. Actrapid was tapered and stopped
on 03/02/2021 and fixed dose insulin regimen
was started.
• Patient was shifted to ward on 03/02/2021
and discharged from the hospital on
05/02/2021.

15. Serial ABG/VBG of patient
Date 31/02/2021 01/02/2021 02/01/2021 02/02/2021 03/02/2021
pH 6.80 7.19 7.37 7.48 7.43
PCO2 12.9 34 26 22.3 27.2
PO2 152 36 28.9 69.9 34.6
HCO3 1.9 13.1 16 19.5 19.7
Na 131 141 130
K 4.8 3.5 3.9
Lactate 1.8 5.2 2.4 3.8 1.1

16. Case Summary
• Ms Parbina Begum, 25 yrs/Female presented to the
Emergency Dept. with complaints of shortness of
breath and restlessness x 2 days & loose stool x 7 days.
• Evaluation revealed uncontrolled blood sugar, severe
metabolic acidosis, positive urine ketones, elevated
total count and anaemia.
• Insulin infusion, IV fluids, NaHCO3 infusion,
Meropenem, Teicoplanin and other supportive
treatment was started in Emergency Dept.
• Patient was admitted in ICU where she improved with
conservative management, observed in ward and
discharged with advice to follow up.

17. Introduction
• Diabetic ketoacidosis (DKA) is an acute, life-
threatening complication of diabetes mellitus.
• DKA occurs predominantly in patients with type 1
diabetes mellitus, but 10% - 30% of cases occur in
newly diagnosed type 2 diabetes mellitus.
• DKA consists of three major abnormalities:
elevated blood glucose level, high ketone bodies,
and a metabolic acidosis with an elevated anion
gap.

18. Pathogenesis of DKA
Tintinalli’s Emergency Medicine;A Comprehensive Guide[3]

19. Classification of DKA
Kitabchi et al[2]

20. Causes of DKA
1. Omission or reduced daily insulin
injections
2. Dislodgement/occlusion of insulin
pump catheter
3. Infection
4. Pregnancy
5. Hyperthyroidism, pheochromocytoma,
Cushing’s syndrome
6. Substance abuse (cocaine)
7. Medications: steroids, thiazides,
antipsychotics, sympathomimetics
8. Heat-related illness
9. Cerebrovascular accident
10. GI hemorrhage
11. Myocardial infarction
12. Pulmonary embolism
13. Pancreatitis
14. Major trauma
15. Surgery

21. Clinical Features : Symptoms
1. Timing
– Rapid onset of symptoms
– Follows febrile illness (40%)
2. Hyperglycemia symptoms
– Polyuria and polydipsia (98%)
– Polyphagia (23%)
3. Gastrointestinal symptoms
– Nausea and Vomiting (50-80%
of cases)
– Abdominal Pain (30% of
patients)
4. Miscellaneous symptoms
– Weight loss (81%)
– Fatigue (62%)
– Dyspnea (57%)
– Weakness
– Lethargy

22. Clinical Features : Signs
1. Mental clouding (lethargy to coma)
1. Metabolic Acidosis findings
– Kussmaul Breathing
– Acetone on breath (sweet or fruity breath smell)
1. Dehydration (often >10% dehydrated)
– Dry Skin with loss of Skin Turgor
– Eyes sunken
– Tachycardia and possibly Hypotension
– Temperature below normal

23. Management goals
• Fluid resuscitation
• Reversal of the acidosis and ketosis
• Reduction in the plasma glucose
concentration to normal
• Replenishment of electrolyte and volume
losses
• Identification of underlying cause

24. Management
of
DKA
[1,2]

25. Bicarbonate therapy
• A prospective randomized study in patients with pH between 6.9
and 7.1 showed that bicarbonate therapy had no risk or benefit in
DKA [7]
• pH between 6.9 and 7.0, it may be beneficial to give 50 mmol of
bicarbonate in 200 ml of sterile water with 10 mmol KCL over two
hours to maintain the pH at > 7.0[8]
• Adult patients with pH < 6.9 should be given 100 mmol sodium
bicarbonate in 400 ml sterile water (an isotonic solution) with 20
mmol KCl administered at a rate of 200 ml/h for two hours until the
venous pH becomes greater than 7.0. Venous pH should be
assessed every 2 hours until the pH rises to 7.0; treatment can be
repeated every 2 hours if necessary.[3,9]

26. References
1. Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi J Med
Med Sci. 2020;8(3):165-173. doi:10.4103/sjmms.sjmms_478_19
2. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes.
Diabetes Care. 2009 Jul;32(7):1335-43. doi: 10.2337/dc09-9032. PMID: 19564476; PMCID: PMC2699725.
3. Tintinalli Judith E. Endocrine Disorders; Tintinalli’s Emergency Medicine.A Comprehensive Guide.Eight
Edition;2016 Chapter 225(pp1457-1464)
4. Das AK. Type 1 diabetes in India: Overall insights. Indian J Endocrinol Metab. 2015;19(Suppl 1):S31-S33.
doi:10.4103/2230-8210.155372
5. Patel MP, Ahmed A, Gunapalan T, Hesselbacher SE. Use of sodium bicarbonate and blood gas monitoring in
diabetic ketoacidosis: A review. World J Diabetes. 2018 Nov 15;9(11):199-205. doi:
10.4239/wjd.v9.i11.199. PMID: 30479686; PMCID: PMC6242725.
6. Duhon B, Attridge RL, Franco-Martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate
therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013 Jul-Aug;47(7-8):970-5. doi:
10.1345/aph.1S014. Epub 2013 Jun 4. PMID: 23737516.
7. Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Annals of internal
medicine 1986; 105:836-840
8. Lever E, Jaspan JB. Sodium bicarbonate therapy in severe diabetic ketoacidosis. Am J Med 1983; 75:263-
268
9. Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And
Hyperglycemic Hyperosmolar State (HHS) [Updated 2018 May 17]. In: Feingold KR, Anawalt B, Boyce A, et
al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK279052/

27. Thank you …!!