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.

2. General and systemic including airway exam. Routine blood investigations: Hb:10gm%, CBC: 20200/cu.mm, RFTs & LFTs: WNL, RBS: 320mg/dl, Serum. electrolytes:- Sr. Na:130mEq/l, Sr. K: 5mEq/l Chest Xray: increased BVM, ECG: NSR, Urine routine microscopy;

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

6. Polyuria Polydypsia Blurred vision Nausea/Vomiting Abdominal Pain Fatigue Confusion Obtundation

7. Tachycardia Dehydration / hypotension Tachypnea / Kussmaul respirations / respiratory distress Abdominal tenderness (may resemble acute pancreatitis or surgical abdomen) Lethargy / obtundation / cerebral edema / possibly coma

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