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CASE PRESENTATION ON
Diabetic Ketoacidosis By, Aromal Satheesh II PHARM-D
Name: xyz
Age: 11yrs. Sex: female Weight: 19 kg Unit: pediatric-II
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
PMHX: NS
Allergy: NKA
DIABETIC KETOACIDOSIS
PROVISIONAL DIAGNOSIS:
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
DAY 1
CBG: 459 mg/dl7:30 pm- 312mg/dl8:30 pm- 192mg/dl
CNS – Lethargic , Adv: ophthalmology opinion
Report: Fundus normal- both eyes
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)
DAY 1…
MICROBIOLOGY
Urine ketones +++ Albumin : nil Sugar : 2% Pus cells: 2-3 Epithelial cells: 1-2
Rx: IVF NS bolus @ 20 ml/ kg over 1 hr.
400ml followed by ½ NS @ 117 ml/ hr
Actrapid insulin iv 5 units qid
TIME THERAPY
1ST HOUR 10-20ml/kg iv bolus 0.9% NaCl or RL.insulin drip at 0.05 to 0.1µ/kg/hr20 ml/kg x 20 kg= 400ml iv bolus
2nd HOUR until DKA resolution
0.45% Saline plus continue insulin drip5% glucose if blood sugar less than 250mg/dl
DKA Treatment Protocol
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
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
BP: 108/60mmHg PULSE: 92bpm
No fresh complaintso/e : afebrile , conscious, alert , oriented hydration adequate urine: ketones -veP/A : soft , CNS : NAD Adv: Stop insulin infusion after given SC with
monitoring
Day 2
IVF- stopped Inj Actrapid 10 units SC qid
CBG 8:30 am – 106 mg/ dl 9:30 am -186 mg/dl
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
DAY 3
CBG : 3:00 am- 379 mg/ dl 9:30 am – 469 mg.dl10 pm- high
BP: 100/68mmHg PULSE:90 bpm
o/e : afebrile urine sugar +++ ketones -ve Adv : Inj.Actrapid 12 units qid proper diet management
DAY 4
CBG: 4 am- 378 mg/dl4 pm- 337 mg / dl10 pm- 229 mg/dl
BP: 100/60 mmHg PULSE:92 bpm Hydration adequateAdv: Diet counselling 10 units qid with CBG monitoring
DAY 5
CBG:5 :30 am -278mg/dl
12 pm- 396 mg/dl6 pm – 425 mg/dl
No fresh complaints No dehydration Adv: Stop Actrapid Start Mixtard insulin 25- 0-15 from tomorrow morning: 15-0-15
Day 6 & 7
DAY 6 DAY 7
CBG12 am- 441 mg/dl6 am- 159mg/dl
12pm – 341mg/dl6pm- 395 mg/dl
CBG1 am- 325mg/dl7am-235mg/dl
10am-202 mg/dl6pm-270 mg/dl
Adv: 15-0-10 units Repeat CBG at midnight & afternoon
Day 8
CBG6 am-74 mg/dl
9:30 am-266mg/dl2:30pm – 225mg/dl
Pulse: 100 bpm
o/e : no fever no dehydration
Adv: 25-0-15 units To give midnight snack
Day 9
CBG1 am-365mg/dl6 am- 186mg/dl
Pulse:102 bpm
o/e : afebrile no signs & symptoms of respiratory distress
Adv: continue 25-0-15 units
Day 10
CBG12 MN-
358mg/dl6 am- 93 mg/dl
Pulse : 88 bpm o/e: RS clear CNS: NAD P/A : soft ,nontender
Day 11
CBG1am-267 mg/dl7am-389mg/dl1pm-328mg/dl7pm-402 mg/dl
Adv: Discharge on insulin 25-0-15 units Follow up regularly
Day 12
CBG12MN- 315mg/dl6am- 102 mg/dl
Drug D R F 8/2 9/2 10/2 11/2 12/2 13/2 14/2
IVF NS bolus
400ml
iv √ - - - - - -
Foll by ½ NS
117ml/hr
iv √ √ sos sos sos sos sos
Actrapid insulin
SC QID 10U 10U 12U 10U 10U -
Paracetamol
170 mg
supp √ sos sos sos sos sos sos
Mixtard
SC BD - - - - - - 25-0 -15
Treatment chart
Drug D R F 15/2 16/2 17/2 18/2
IVF NS bolus
- - - - - - -
Foll by ½ NS
- - - - - - -
Actrapid insulin
SC - - - -
Paracetamol
170 mg
supp sos sos sos sos sos
Mixtard
SC BD 15-0-10
25-0-15
25-0-15
25-0-15
Subjective
fever
polyuria polydipsia &
polyphagia
Objective
Urine ketones +++Urine sugar : 2%Elevated RBS:
454mg/dl (70-150)
PHARMACEUTICAL CARE PLAN
DIABETIC KETOACIDOSIS
FINAL DIAGNOSIS
Fluid & electrolyte balanceCorrection of hyperglycemiaTo prevent hypokalemia & cerebral edema
GOALS OF THERAPY
IV Fluids
Insulin preparations: Rapid acting- Lispro , Aspart ,
Glulisine Intermediate acting – NPH Long acting – Glargine , Detemir
TREATMENT OPTIONS
Sign & symptoms of dehydration was reduced by Day 2
Urine ketones were absent by Day 2
GOALS ACHIEVED
Blood Glucose levelsBody weightElectrolytes Urine ketone & urine sugarSymptoms of hyperglycemiaSymptoms of cerebral edemaDiet habits
MONITORING PARAMETERS
Bicarbonate level not monitored
PROBLEMS IDENTIFIED
ABOUT THE DISEASE sign & symptoms complications
ABOUT THE MEDICATION purpose & dose importance of medication adherence possible adverse effects
PATIENT COUNSELLING
ABOUT LIFESTYLE MODIFICATION Diet Exercise
Thank You
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