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CASE PRESENTATION ON Diabetic Ketoacidosis By, Aromal Satheesh II PHARM-D

CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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Page 1: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

CASE PRESENTATION ON

Diabetic Ketoacidosis By, Aromal Satheesh II PHARM-D

Page 2: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Name: xyz

Age: 11yrs. Sex: female Weight: 19 kg Unit: pediatric-II

Page 3: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 4: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

PMHX: NS

Allergy: NKA

Page 5: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

DIABETIC KETOACIDOSIS

PROVISIONAL DIAGNOSIS:

Page 6: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 7: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

CNS – Lethargic , Adv: ophthalmology opinion

Report: Fundus normal- both eyes

Page 8: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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…

Page 9: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

MICROBIOLOGY

Urine ketones +++ Albumin : nil Sugar : 2% Pus cells: 2-3 Epithelial cells: 1-2

Page 10: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Rx: IVF NS bolus @ 20 ml/ kg over 1 hr.

400ml followed by ½ NS @ 117 ml/ hr

Actrapid insulin iv 5 units qid

Page 11: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 12: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 13: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 14: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 15: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

IVF- stopped Inj Actrapid 10 units SC qid

CBG 8:30 am – 106 mg/ dl 9:30 am -186 mg/dl

Page 16: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 17: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 18: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 19: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

No fresh complaints No dehydration Adv: Stop Actrapid Start Mixtard insulin 25- 0-15 from tomorrow morning: 15-0-15

Day 6 & 7

Page 20: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 21: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 22: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 23: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 24: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 25: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Adv: Discharge on insulin 25-0-15 units Follow up regularly

Day 12

CBG12MN- 315mg/dl6am- 102 mg/dl

Page 26: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 27: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

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

Page 28: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Subjective

fever

polyuria polydipsia &

polyphagia

Objective

Urine ketones +++Urine sugar : 2%Elevated RBS:

454mg/dl (70-150)

PHARMACEUTICAL CARE PLAN

Page 29: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

DIABETIC KETOACIDOSIS

FINAL DIAGNOSIS

Page 30: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Fluid & electrolyte balanceCorrection of hyperglycemiaTo prevent hypokalemia & cerebral edema

GOALS OF THERAPY

Page 31: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

IV Fluids

Insulin preparations: Rapid acting- Lispro , Aspart ,

Glulisine Intermediate acting – NPH Long acting – Glargine , Detemir

TREATMENT OPTIONS

Page 32: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Sign & symptoms of dehydration was reduced by Day 2

Urine ketones were absent by Day 2

GOALS ACHIEVED

Page 33: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Blood Glucose levelsBody weightElectrolytes Urine ketone & urine sugarSymptoms of hyperglycemiaSymptoms of cerebral edemaDiet habits

MONITORING PARAMETERS

Page 34: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Bicarbonate level not monitored

PROBLEMS IDENTIFIED

Page 35: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

ABOUT THE DISEASE sign & symptoms complications

ABOUT THE MEDICATION purpose & dose importance of medication adherence possible adverse effects

PATIENT COUNSELLING

Page 36: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

ABOUT LIFESTYLE MODIFICATION Diet Exercise

Page 37: CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)

Thank You