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Diabetic Ketoacidosis

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PBL

PBLCASEAn 18-year-old female was taken to the emergency room in comaHer parents noticed that she had polydipsia, polyuria, and rapid weight loss which started approximately 1 month ago and had worsened in the last weekShe had not been taking any medications and the clinical history was otherwise unremarkableOn examinationbreathing was deep and rapid (Kussmaul respiration), pulse rate was 100 beats per minute, and blood pressure 110/70 mmHg; she also had signs of dehydrationCNS - She was drowsy and confused, no FNDCVS S1 and S2 heardRS NVBS, No added sounds

INVESTIGATIONS hematocrit 44%, hemoglobin 13 g/dl white blood cell count 12,000/ l, glucose 520 mg/dl urea 50 mg/dl creatinine 1.0 mg/dl Na+ 130 mEq/L K+ 4.6 mEq/L, PO4 2.0 mEq/L Cl 112 mmol/L Mg 1.6Arterial pH was 7.0, PO 98 mmHg, PCO 25 mmHg, HCO 12 mEq/L AG 16O 2 sat 98%.Serum Osmolality 306What is your diagnosis?Which additional biochemical tests are required to confirm the diagnosis?Precipitating events? Inadequate insulin administration

Infection (pneumonia/UTI/gastroenteritis/sepsis)

Infarction (cerebral, coronary, mesenteric, peripheral)

Drugs (cocaine)

Pregnancy

Symptoms and signsPolyuria, thirstWeight loss Weakness Nausea, vomiting Leg cramps Blurred vision Abdominal pain DehydrationHypotension (postural or supine) Cold extremities/peripheral cyanosis Tachycardia Air hunger (Kussmaul breathing) Smell of acetone Hypothermia Confusion, drowsiness, coma (10%) Management?Fluids

Fluid replacementTime: 060 minsCommence 0.9% sodium chlorideIf systolic BP > 90 mmHg, give 1 L over 60 minsIf systolic BP < 90 mmHg, give 500 mL over 1015 mins,then re-assess

60 mins to 12 hrsIV infusion of 0.9% sodium chloride with 40 mmol/L potassium chloride added as indicated below1 L over 2 hrs1 L over 4 hrs1 L over 6 hrsIf plasma sodium is > 155 mmol/L, 0.45% sodium chloride maybe usedWhen hemodynamic stability and adequate urine output are achieved, IV fluids should be switched to 0.45% saline at 250500 mL/hInsulinIf the initial serum potassium is 5.5 Nil3.55.5 40< 3.5 additional potassium requiredCardiac rhythm should be monitored in severe DKA because of the risk of electrolyte-induced cardiac arrhythmia.Bicarbonate, Mg, Po4Adequate fluid and insulin replacement should resolve the acidosis. The use of intravenous bicarbonate therapy is currently not recommendedsevere acidosis (arterial pH 7.0Hypomagnesemia may develop during DKA therapy and may also require supplementation.serum phosphate < 1 mg/dL, then phosphate supplement should be considered and the serum calcium monitoredMonitoring Hourly capillary blood glucose testingVenous bicarbonate and potassium after 1 and 2 hrs, thenevery 2 hrsPlasma electrolytes every 4 hrsClinical monitoring of O2 saturation, pulse, BP, respiratory rate and urine output every hourIf ketoacidosis has resolved and patient is able to eat and drinkRe-initiate SC insulinDo not discontinue IV insulin until 30 mins after SC short-acting insulin injectionHyperglycaemic hyperosmolar statesevere hyperglycaemia >600 mg/dLhyperosmolality serum osmolality > 320 mOsm/kg Dehydration in the absence of significant hyperketonaemia(< 3 mmol/L) or acidosis (pH > 7.3, bicarbonate> 15 mmol/L).hyperglycaemia usually develops over a longer period, causing more profound hyperglycaemia and dehydrationfluid loss may be 1022 litres in a person weighing 100 kgtypically occurs in the elderlyCommon precipitating factors include infection, myocardial infarction,cerebrovascular events drug therapy (e.g. corticosteroids).Give fluid replacement with 0.9% sodium chloride (IV)Use 0.45% sodium chloride only if osmolality is increasing, despite positive fluid balanceTarget fall in plasma sodium is 10 mmol/L at 24 hrsAim for positive fluid balance of 36 L by 12 hrsreplacement of remaining estimated loss over next 12 hrsInitiate insulin IV infusion (0.05 U/kg body weight/hr) only when blood glucose is not falling with 0.9% sodium chlorideReduce blood glucose by no more than 5 mmol/L/hr

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