ccd DKA

1. CLINICAL CASE
DISCUSSION
Dr Shinde Viraj Ashok
Junior Resident - 2
Department of Pharmacology
GMC Nagpur

2. Patient details
• Name – Sangita Sunil Nikam
• Age / Sex – 30yrs /F
• Registration no – 1204972
• Date of admission – 9/6/2015 at 4.10pm
• Diagnosis – Diabetic ketoacidosis

3. CMO notes on 9/6/2015
• Patient referred from private hospital
• Patient was a k/c/o diabetes mellitus
• Chief complaints
• Fever since 3 days
• Disoriented since 1 day
• Discomfort since 1 day

4. CMO notes on 9/6/2015
• O/E
• GC – Poor
• Afebrile
• Breath smell fruity
• Pulse – 86 bpm
• Blood pressure – 130/70mm of Hg
• Systemic examination
• RS – NAD
• CVS – NAD
• CNS - Disoriented
Treatment IV line secured

5. Admission notes
9/6/2015
• 30yrs F brought by relatives with c/o
• Fever since 2 – 3 months
• Altered sensorium since 2 days
• Breathlessness since 2 days
• Patient was admitted in private hospital and referred as
case of diabetes mellitus with urinary tract infection with
diabetic ketoacidosis

6. 9/6/2015
Patient details
• O/E
• GC – moderate
• Afebrile
• Irritable
• Systemic examination -
• Chest – clear
• P/A – soft non tender
• CNS – conscious
disoriented
Investigations
• R – BSL – 181mg%
• Urine ketones – present
• Pus cells in urine – 20-30/mm3
• Sr Na+ - 132meq/L
• Sr K+ - 3.7meq/L
• USG abdomen – small uretric
calculi in right ureter with
right kidney hydronephrosis

7. Treatment received
• 1 DNS fast
• 2 NS fast
• 2 RL fast
• Inj taxim ( cefotaxime ) stat
• Inj metro ( metronidazole) stat
• RBS monitoring
• Urine ketones monitoring

8. 9/6/2015
• 10 U insulin stat sc
• Insulin drip 80 U over 8hrs
• 3 NS & 3 RL over 4 hrs
• Inj cifran 200mg bd
• Inj rantac 50mg bd
• 80meq KCl over 8hrs
• Inj metro ( metronidazole ) 0.5gm tds
• 2hrly R –BSL with urine ketones monitoring

9. 10/6/2015
Patient details
• O/E
• Afebrile
• P – 90bpm
• BP –110 /70 mm of Hg
• No lymphadenopathy
• S/E
• RS – NAD
• P/A – no guarding rigidity
Tenderness +all over abdomen
• I/O – 1000ml/1600ml
Treatment received
• Inj KCl 40meq in 1 NS
over 4hrs
• 2 NS
• 2 RL
• 4 hrly R – BSL & urine
ketone monitoring
• Inj cifran 200mg iv bd
• Inj metro 0.5gm tds

10. 11/6/2015
Patient details
• O/E
• GC - moderate
• Afebrile
• P – 90bpm
• BP – 110 /70 mm of Hg
• S/E
• RS – NAD
• P/A – soft
• I/O -500ml / 1100ml
Treatment received
• Inj KCl 40meq in 1 NS over
4hrs
• 2 NS
• 2 RL
• 4 hrly R – BSL & urine
ketone monitoring
• Inj cifran 200mg iv bd
• Inj metro 0.5gm tds

11. 12/6/2015
Patient details
• O/E
• GC - moderate
• Afebrile
• P – 90bpm
• BP – 130 /80 mm of Hg
• S/E
• RS – NAD
• P/A – soft
• BSL –R - 201mg%
• Urine ketones – trace
• Advice – urine culture &
sensitivity
Treatment received
• Inj monocef 1gm iv bd
• Inj KCl 4meq
• Inj metro 0.5mg iv tds
• 1 NS
• 2 NS
• 2 RL
• 2 NS + 2 RL over 5 hrs
• 1 DNS with 30 U insulin
over 5hrs
• Tb FA 1od
• Tb FS 1bd

12. 13/6/2015
Patient details
• O/E
• GC - moderate
• Afebrile
• P – 90bpm
• BP – 120 /80 mm of Hg
• S/E
• RS – NAD
• P/A – soft
• BSL –R -291mg%
• Urine ketones – present
• Dengue IgM – Neg
• HRP 2 - Neg
Treatment received
• Inj monocef 1gm iv bd
• Inj KCl 4meq - omit
• Inj metro 0.5gm iv tds
• 1 NS
• 2 NS
• 2 RL
• 2 NS + 2 RL over 5 hrs
• 1 DNS with 30 U insulin
over 5hrs
• Tb FA 1od
• Tb FS 1bd

13. 14/6/2015
Patient details
• O/E
• GC – moderate
• Afebrile
• P – 90bpm
• BP – 120 /80 mm of Hg
• S/E
• RS – NAD
• P/A – soft
• BSL –R - 291mg%
• Urine ketones - small
• Gynac reference was advised
• Hb – 7.4 gm%
• TLC – 22300/mm3
• Plt – 43000/mm3
Treatment received
• Inj monocef 1gm iv bd
• Inj metro 0.5mg iv tds
• 1 NS
• 2 NS
• 2 RL
• 2 NS + 2 RL over 5 hrs
• 1 DNS with 30 U insulin
over 5hrs
• Tb FA 1od
• Tb FS 1bd

14. 15/6/2015
Patient details
• O/E
• GC – moderate
• Afebrile
• P – 90bpm
• BP – 120 /80 mm of Hg
• S/E
• RS – NAD
• P/A – soft
Treatment received
• Inj monocef 1gm iv bd
• Inj metro 0.5mg iv tds
• 1 NS
• 2 NS
• 2 RL
• 2 NS + 2 RL over 5 hrs
• 1 DNS with 30 U insulin
over 5hrs
• Tb FA 1 od
• Tb FS 1 bd

15. 15/6/2015 at s/b lect/ AP
Patient details
• O/E
• GC – moderate
• Afebrile
• P – 100bpm
• b/l oedema over feet ++
• S/E
• RS – NAD
• P/A – soft
Treatment received
• Inj piptaz 2.25mg tds
• Inj metro 0.5gm tds
• Inj larinate( artesunate)
120mg iv od
• 2 NS
• 2 RL
• 2 DNS with 4 U regular
human insulin

16. 15/6/2015 s/b SP
Patient details
• O/E
• GC - moderate
• Afebrile
• P – 88bpm
• b/l oedema over feet ++
• S/E
• RS – NAD
• P/A – soft
• pH – 7.26
• HCO3- - 7.2 mmol/L
• P CO2 – 16mm of Hg
Treatment received
• Inj meropenem 0.5 gm iv
bd
• Inj metro 500mg iv tds
• Tb linezolid
• With hold piptaz

17. Diabetic ketoacidosis
• Diabetic ketoacidosis (DKA) is a acute complications of
diabetes.
• Primarily seen in type 1 DM.
• Associated with absolute or relative insulin deficiency,
volume depletion, and acid-base abnormalities.
• Associated with potentially serious complications if not
promptly diagnosed and treated.

18. Insulin lack
Hyperglycemia
Glycosuria
Loss of electrolytes
Osmotic diuresis
Intracellular K+
depletion
Hypotension ,
shock ,tachycardia
Ketosis
Acidosis
Loss of fixed
cations in urine
Loss of water
Dehydration
Hyperosmolarity
of blood
Ketonuria Vomiting Impairment
of glucose
entry into
brain
Hyperventilation
Impairment of consciousness
Intracellular
dehydration

19. Diabetic ketoacidosis
Standard treatment
Confirm diagnosis ( plasma glucose, positive serum ketones, metabolic
acidosis).
Admit to hospital; intensive-care setting may be necessary for frequent
monitoring or if pH <7.00 or unconscious.
1. IVF – 0.9% saline, 0.45% saline
2. Administration of short acting insulin.
3. Monitoring - Capillary glucose , Electrolytes, blood pressure, pulse,
respiration ,temperature ,mental status.
4. Assessment of patient - noncompliance, infection, trauma,
infarction ?

20. Standard treatment cont.
5. K+ correction - 10- 20meq/hr of KCl after 4hrs.
6. Inj sodium bicarbonate – arterial blood pH < 7.1
acidosis is not corrected spontaneously or
hyperventilation is exhausting.
7. Administration of long acting insulin – as patient starts
eating

21. Rationality
IVF – 0.9% NS
• Use –Rational
• Initial infusion of normal saline - replacement of the
sodium and correction of dehydration.
• Patient was not shifted to 0.45 % NS which is indicated
once volume status has improved. It might have lead to
pedal oedema.
• In this case patient should have been given fluids based
CVP monitoring.

22. Rationality
Inj short acting insulin
• Use – rational
• IV administration is preferred (0.1 units/kg of regular
insulin per hour), because it ensures rapid distribution and
allows adjustment of the infusion rate as the patient
responds to therapy.
• Subcutaneous is not relied up on in diabetic ketoacidosis.

23. Rationality
Inj KCl
• Use – rational
• During treatment with insulin and fluids, various factors
contribute to the development of hypokalemia.
• Insulin-mediated potassium transport into cells, resolution
of the acidosis (which also promotes potassium entry into
cells), and urinary loss of potassium salts of organic
acids.

24. Rationality
• Inj cifran (ciprofloxacin)
• Inj taxim (cefotaxime)
• Inj monocef (ceftriaxone)
• Inj metronidazole
• Inj meropenem
• Tb linezolid
• Use – irrational
• Either ciprofloxacin or cefotaxime should have been started
empirically till report of culture & sensitivity becomes
available.

25. Rationality
Inj larinate ( artesunate )
• Use – irrational
• There was evidence of urinary tract infection but there
were no signs & symptoms of malaria.
• Patient was written afebrile since day 1.

26. Not Rationale
• No advice regarding diet was mentioned any where.
• Brand names were used.
• Initially DNS should not have been given.
• When hemodynamic stability and adequate urine output is
achieved, IV fluids should have been switched to 0.45%
saline depending on the calculated volume deficit which
was not done.

27. Not rationale
• Urine & blood culture & sensitivity was done on
12/6/2015on 4th day. Samples for urine & blood culture
sensitivity should be taken before starting treatment.
• Temperature charts were not maintained.
• BSL & insulin charts were missing.

28. Not rationale
• Antimicrobial use was irrational.
• At some places doses and route of administration were
missing.

30. Standard treatment
• IVF
• Replace fluids: 2-3 L of 0.9% saline over first 1-3 h ? (15-
20 mL/kg per hour);
• 0.45% saline at 250-500 mL/h;
• Change to 5% glucose and 0.45% saline at 150-250 mL/h -
plasma glucose reaches 200 mg/dL (11.2 mmol/L).
• Monitoring
• Capillary glucose every 1-2 h
• Electrolytes (especially K+, bicarbonate, phosphate) and
anion gap every 4h for first 24 h.

31. Standard treatment
cont…
• Assess patient:
• What precipitated the episode (noncompliance, infection,
trauma, infarction, cocaine)?
• Initiate appropriate workup for precipitating event
(cultures, CXR, ECG)
• Administration of insulin
• Administer short-acting insulin: IV (0.1 units/kg),
• Then 0.1 units/kg per hour by continuous IV infusion;
• Increase two- to threefold if no response by 2-4 h.

32. Standard treatment cont ..
• K+ correction
• If serum potassium is <3.3 mmol/L (3.3 meq/L), do not
administer insulin until the potassium is corrected.
• If serum potassium is >5.2 mmol/L (5.2 meq/L), do not
supplement K corrected
• Replace K+: 10 meq/h when plasma K+ < 5.0凡5.2
meq/L (or 20-30 meq/L of infusion fluid), ECG normal,
urine flow and normal creatinine documented; administer
40-80 meq/h when plasma K+ < 3.5 meq/L or if
bicarbonate is given.

33. Standard treatment
cont…
• Monitor blood pressure, pulse, respirations, mental
status, fluid intake and output every 1- 4 h.
• Above treatment is continued until
• Glucose goal is 8.3-13.9 mmol/L (150- 250 mg/dL), and
acidosis is resolved.
• Insulin infusion may be decreased to 0.05-0.1 units/kg per
hour.
• Administer long-acting insulin as soon as patient is
eating. Allow for overlap in insulin infusion and SC
insulin injection.