A 55 year male patient was brought by relatives to the ESR with c/o pain and swelling over lt foot extending upto below knee.Pt also c/o abdominal pain and drowsiness since two days. O/E:- P:120 bpm, BP:-100/60 mmHg, RR:-30cpm, Per abdomen exam reveals tenderness.
1. A 55 year male patient was brought by relatives to the ESR
with c/o pain and swelling over lt foot extending upto below
knee.Pt also c/o abdominal pain and drowsiness since two days.
O/E:- P:120 bpm, BP:-100/60 mmHg, RR:- 30cpm, Per abdomen exam
reveals tenderness.
3. Special investigations: Serum and urine ketones: ++, ABG:-
pH:7.25, pO2:90, pCO2:28, Sr bicarbonate:15, BE:-9, SO2:97%If a
classic triad of DKA i.e hyperglycemia, ketonemia and metabolic
acidosis is seen,diagnosis
4. A state of absolute or relative insulin deficiency
aggravated by ensuing hyperglycemia, dehydration, and acidosis-
producing derangements in intermediary metabolism, including
production of serum acetone. Can occur in both Type I Diabetes and
Type II Diabetes In type II diabetics with insulin
deficiency/dependence The presenting symptom for ~ 25% of Type I
Diabetics
5. Stressful precipitating event that results in increased
catecholamines, cortisol, glucagon. Infection (pneumonia, UTI)
Alcohol, drugs Stroke Myocardial Infarction Pancreatitis Trauma
Medications (steroids, thiazide diuretics) Non-compliance with
insulin
8. INSULIN Administer short-acting insulin: IV (0.1 units/kg)
or IM (0.3 units/kg), then 0.1 units/kg per hour by continuous IV
infusion; Increase 2- to3-fold if no response by 24 h. If initial
serum potassium is < 3.3 meq/l,correct K level while giving
insulin to prevent dangerous hypokalemia. Expected fall is 50-100
mg/h Transition into SQ when: A. Plasma glucose is less than 250
mg/dl B. DKA has resolved (usually less than 12 hs) C. Patient is
tolerating PO
9. FLUID1. Deficit is around 6-8 L need NOT to replace all of
it with IV fluid Replace fluids: 23 L of 0.9% saline over first 13
h (1015 mL/kg per hour); Subsequently 0.45% saline at 150300mL/h;
Change to 5% glucose and 0.45% saline at 100200 mL/h when plasma
glucose reaches 250 mg/dL (14 mmol/L). Watch BP, pulse,
BUN/creatinine and urinary output. Use plasma expanders/blood if in
shock and does not respond quickly to saline.
10. ELECTROLYTES1. The critical is K2. There is always a
deficit, but blood levels may be low, normal or high3. Frequent EKG
and serum levels are mandatory4. Initially IV may be the only way
to administer K but remember that once PO is re-established, K can
be given orally. Factors reducing serum K+ Rehydration urinary
secretion of K+ Insulin administration moves K+ from extracellular
to intracellular.
11. Replace K+: 10 meq/h when plasma K+ < 5.5 meq/L, ECG
normal, urine flow and SERUM K LOW (5.0) pH < 7.0 normal 10-20
meq or EKG changes plasma K+ < 3.5 meq/L or if bicarbonate is
given.
12. BICARBONATE1. Usually NOT necessary2. It may even be
dangerous and precipitate hypokalemia, cerebral acidosis and
cardiac dysfunction3. For very severe acidosis (pH