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A Case of Study Lyndon Woytuck

Diabetic ketoacidosis: a case study

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A Case of Study

A Case of StudyLyndon Woytuck

PresentationYA admitted 12/11/201619 years old, male, single, employed in military in janitorialPolyuria of 2 weeks duration

Frequent urination up to once per hourAccompanied by intense thirst and dry mouthDrinking water every hour to compensate for urinationConsumed some powder last month to increase muscle massWeight loss of 3kg in 2 weeks, weight 56kg nowPolydipsia, general weakness and abdominal painUsed to running a time of 11:30min and now 13:40minDiffuse abdominal pain began 2 days prior to admissionGradually worsened until admission, then improved in hospitalNo change in urine appearance or odour, no gross haematuriaNo fever, no nausea, no vomiting, no diarrhoeaBackground: G6PD, non-modified diet; NKDA

What could it be?Type 1 DMMonogenic DM (previously MODY) (5% of paediatric cases)Diabetes is diagnosed within 6 months of birthA strong family history of diabetes is present, without type 2 features (eg, obesity or higher-risk ethnicity)Mild fasting hyperglycemia is observed, especially in young, non-obese childrenDiabetes is present, but islet cell autoantibodies, obesity, and insulin resistance are absentSecondary hyperglycaemiaEndocrine tumourDrugs: thiazides, phenytoin, glucocorticoidsPancreatitisWhen in doubt, treat the patient with insulin and close monitoring of glucose levels. It is not unusual for adolescents or young adults, particularly Hispanic or African-American patients, to present with DKA and subsequently be found to have type 2 DM

What should be the initial management?Acute hyperglycaemia is harmful>240mg/dL osmotic diuresis ensues, with loss of glucose, electrolytes, and waterno absolute level of blood glucose elevation mandates admission to the hospital or administration of insulin in the ED In general, lowering glucose in the ED does not correct underlying cause and has no long-term effect on the patients glucose levels. Volume repletion, insulin therapy, and specific metabolic corrections are the keys to treatment in DKA and acute hyperglycaemiaWBC, blood and urinecultures to rule out infection.Urine ketones are not reliable for diagnosing or monitoring DKA, but may show if hyperglycemic individual may have a degree of ketonemia..beta-hydroxybutyratelevelis a more reliable indicator of DKA, with plasma bicarbonate or arterial pH

How much insulin?The insulin coverage, with a sliding scale for insulin administrationNot alone, because it is reactive rather than proactive. The initial daily insulin dose is calculated by patient weight. Usually one half is administered before breakfast, one fourth before dinner, and one fourth at bedtime. Then adjust the amounts, types, and timing according to the plasma glucose levels so that preprandial plasma glucose is 80-150 mg/dL (4.44-8.33 mmol/L)Moderate hyperglycemia without ketonuria or acidosissingle daily subcutaneous injection of 0.3-0.5 U/kg of intermediate insulinHyperglycemia and ketonuria without acidosis or dehydration 0.5-0.7 U/kg of intermediate insulin and SC 0.1 U/kg regular q4-6hr In HHS, begin a continuous insulin infusion of 0.1 U/kg/hMonitor blood glucose every hour at bedside; if glucose levels are stable for 3 hours, decrease the frequency of testing to every 2 hoursSet target blood glucose level at 250-300 mg/dL; adjust downwards after the patient is stabilized and increase or decrease by 0.5U/h per 50mg/dL rangeContinue intermediate-acting (ie, NPH or Lente) insulin at 50-70% of the daily dose divided into 2 or, occasionally, 3-4 daily doses. Administer supplemental regular insulin on a sliding scaleBlood glucose should be monitored before meals and at bedtime

Immediate ManagementAttended clinic at the military base and referred to ERIn ER, blood glucose was found to be >600mg/dL on fingerstick test and insulin was administeredActrapid 10IU SC and Actrapid 7IU IV and 1000mL 0.9% NaCl givenMetoclopramide 10mg IVKCl administration initiatedNo blood gas disturbance, acidaemia or ketoacidosisGlycosuria ++++ Ketonuria ++++Glucose confirmed in serum 722mg/dL

ECG Sinus rhythm and regularChest X Ray clear and symmetric bilaterally

DiagnosisType 1 Diabetes mellitus is characterised by the inability of beta islet cells to produce insulin due to autoimmune destructionClassic symptoms are Polydipsia, Polyuria, Polyphagia, and Unexplained weight lossOnset of symptoms may be sudden and may present with DKAAmerican Diabetic Association CriteriaA fasting plasma glucose (FPG) level 126 mg/dL (7.0 mmol/L),orA 2-hour plasma glucose level 200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test (OGTT),orA random plasma glucose 200 mg/dL (11.1 mmol/L) in a patient with classic symptoms of hyperglycemia or hyperglycemic crisisHbA1cassay for diagnosing type 1 diabetes only when the condition is suspected but the classic symptoms are absent.

Why did he present with this episode now?There is a combined effect of lymphocytic infiltration and destruction of insulin-secreting beta cells of the islets of Langerhans in the pancreasCell mass declines, insulin secretion decreases until insulin amount is too small to maintain normal blood glucose levelsAfter 80-90% of the beta cells are destroyed, hyperglycemia developsAutoimmunity in genetically susceptible may be triggered by viral infection and production of antigenically similar molecules (eg, enterovirus,mumps, rubella, and coxsackievirus B4)85% have islet cell antibodies and those directed against glutamic acid decarboxylase (GAD)Correlated with Graves, Hashimotos, and AddisonsApproximately 95% of patients with type 1 DM have either HLA-DR3 or HLA-DR4 polymorphisms

What are the next steps?Patients need exogenous insulin to reverse this catabolic condition, prevent ketosis, decrease hyperglucagonemia, and normalize lipid and protein metabolism.Prevent hypoglycaemia due to management errorsPrevent or delay microvascular and macrovascular complications by maintaining good glycaemic controlSensory and autonomic neuropathyAngiopathyNephropathyInfectionDouble diabetes

In hospital ManagementHyperglycaemia due to Type I DM (new diagnosis)

Insulin therapy continuedApidra 8U SC once daily (fast)Lantus 16U SC once daily (long)InvestigationsUrine output 1000mL overnightHbA1c - 11.0% 13/11CRP and WBC - normalLFTs - ALP 153Us and Es - normalMg 1.80Glucose 291mg/dL on 13/11Gluc 283 per urine

What should happen for discharge and follow-up?Consider patient age for glycemic goals, with different targets for preprandial, bedtime/overnight, and HbA1c levels in patients aged 0-6, 6-12, and 13-19Benefits of tight glycemic control include continued reductions in the rate of microvascular complications and significant differences in cardiovascular events and overall mortalitySelf-monitoringOptimal control requires frequent blood glucose measurement, which allows rational adjustments in insulin doses. Record blood glucose levels at home and adjust accordingly (CGMs)Insulin therapylifelong insulin therapy Usually 2 or more injections of insulin dailybasal insulin and a preprandial (premeal) insulin. The basal insulin is either long-acting (glargine or detemir) or intermediate-acting (NPH). The preprandial insulin is either rapid-acting (lispro, aspart, insulin inhaled, or glulisine) or short-acting (regular).Diet and activitycomprehensive diet plan, with a professional dietitianA daily caloric intake prescriptionRecommendations for amounts of dietary carbohydrate, fat, and proteinInstructions on how to divide calories between meals and snacksPatients should be encouraged to exercise regularly.

Discharge ManagementEndocrinological consultationDM diagnosis information and management educationDischarge with endocrinological and GP follow-upUse every opportunity to educate the patient and the parents or caregiver about the disease process, management, goals, and long-term complicationssigns and symptoms of hypoglycemia and how to manage itthe course of diabetes: they have a chronic condition that requires lifestyle modification and they are likely to have chronic complications if they do not take control of their diseaseReassure patients about the prognosis with proper managementPay attention to older adolescents who may become detached from health careA dietitian should provide specific diet control education A nurse should educate the patient about selfinsulin injection and performing fingerstick tests

ReferencesMedScape www.Medscape.comUpToDate www.uptodate.com