1. DIABETIC KETOACIDOSIS: A CASE STUDY
Dr. Prashant Kadam

2. COULD THIS HAVE BEEN PREVENTED?
9 year old HARDIK, a known diabetic since past one year, on insulin Rx, developed fever & cough with loss of appetite.
Since he was not eating, the parents, fearing hypoglycemia, omitted his insulin dose.
As the day progressed he developed abdominal pain and distension with vomiting and became breathless and drowsy

3. Capillary refill: mildly prolonged,
EXAMINATION
HR: 130 /min RR: 50 /min BP:100/60
Severe dehydration,
Capillary refill: mildly prolonged,
Drowsy but no other neurological signs,
Air hunger with bilateral good air entry and no foreign sounds,
Abdominal distension, liver 2 cm+

4. BEDSIDE DIAGNOSIS IN < 2 MIN
Finger prick BG: HIGH (600 mg %)
Urine Ketones ++++
Diagnosis: Diabetic ketoacidosis

5. Samples collected for:
ABG: pH: 6.92; pCo2: 4.5; HCo3: 1.1
CBC
Electrolytes
Creatinine and BUN
Serum Ketones
Serum Amylase
Blood and Urine Culture
Urine Routine.

6. IV INFUSION STARTED BEFORE SAMPLES DESPATCHED TO LAB….
BG at the end of 1st
hour : 497 mg%
(down by 103 mg%)
300 ml NS over 1hr
(10 ml/kg)
No insulin
No bicarbonate
No antibiotics

7. BASELINE LAB REPORTS CBC: 15.1 /55/23600 – P85, no band forms,/6 lacs
Serum Electrolytes: 139 / 5.2 / 100.
BUN: 25
Creatinine: 0.9
Serum Ketones +ve
Serum Amylase: 163

8. DO NOT TAKE LAB REPORTS AT FACE VALUE…
Corrected Na + = 139 +( 500 x 1.6 / 100 )
= 147
Anion Gap = Na – ( Cl + HCo3 )
= 139 – ( ) = 37.9
(normal = )
Calculated Serum Osmolality
= 2 x Na + BG /18+ BUN/2.8
= 2 x /18 +25/2.8 = 319
Effective serum Osmolality = 311

9. INSULIN INFUSION: STARTED AT END OF 1ST HOUR
50 IU INSULIN ‘R’ in 500 ml NS
1 ml/Kg/hr would provide 0.1U/kg/hr
In our case, 30 ml / hr.
50 ml run off from tubing.

10. FLUID CALCULATION: 2ND HOUR ONWARD HOW MUCH TO GIVE?
Maintenance: (M)
1700 ml / 23 hrs = 70 ml/hr
Deficit: (D)
9 % dehydration
90ml/kg = 2700 ml – 300 ml (fluid bolus)
= 2400 ml / 47 hrs = 50 ml/hr
Ongoing losses: not added
So, the fluid / hr = 70(M) + 50(D) = 120 ml/hr

11. WHICH FLUID?
BG > 250 mg%: ½ NS + KCL
BG < 250 mg%: ½ DNS + KCL

12. HOW MUCH POTASSIUM? SERUM K+ KCL in Meq/L > 5.5 NIL 3.5-5.5 20-30
(1-1.5ml/100mlfluid)
40-60
(2-3 ml/100mlfluid)

13. BLOOD GLUCOSE TREND WITH Rx
PERIOD
BLOOD GLUCOSE
baseline
600
1 hr
497
2 hr
458
3 hr
380
4 hr
292
5 hr
240
6 hr
200

14. ELECTROLYTE & ABG TRENDS IN 1ST 6 HOURSHr
Electrolyte
Na / K / Cl
ABG
Ph / PCo2 / HCO3
139 / 5.2 / 100
6.92 / 4.5 / 1.1 2
142 / 4.8 / 104
7.00 / 15 / 4.2 4
144 / 3.9 / 107
7.14 / 18 / 7.0 6
145 / 3.4 / 110
7.22 / 18.5 / 8.5

15. ANION GAP & OSMOLARITY TRENDSHr
Anion Gap
Urine ketones
Corrected Na+
Serum
OSM
37.9
++++
147.0
311 2
33.8
147.5
308 4
30.0
146.7
303 6
26.5
146.6
301

16. By the end of 6 hours Hardik was alert and his breathlessness settled .

17. SUBSEQUENT MANAGEMENT
Fluids were tailored to maintain BG in range of mg%, Electrolytes in normal range
D10% with CRL was used to provide 5-10% dextrose whenever BG < 150 mg%
Insulin drip continued till acidosis was corrected.
Clinical assessment of CNS monitored with gradual normalization of serum Osmolality.

18. 7TH- 14TH HOUR Hr BG PH HcO3 AG OSM 7 172 7.22 8.5 26.5 301 8 110 9
148 10
188
7.28
12.8 23
298 11
154 12
140 13
130 14
144
7.32
15.0 21
300 18
179
7.38
18.0 17
297

19. IV treatment continued till the child accepted oral feeds in morning.
Subcutaneous insulin started as combination ( regular + NPH ) ,total dose of 1 u /kg/day, 2/3 of which (20 U) given as mix of 8R+12NPH BBF.
Insulin infusion & IV fluids discontinued after 45 mins of SC insulin.

20. DIABETIC KETOACIDOSIS: TAKE HOME MESSAGES

21. THM-1) DKA CAN & SHOULD BE PREVENTED
HARDIK, …. “developed fever & cough with loss of appetite.
Since he was not eating, the parents, fearing hypoglycemia, omitted his insulin dose”.

22. SICK DAY GUIDELINES: (follow your BG not your appetite)
Continue usual insulin dose (except: BG< 80)
Check BG & urine ketones every 4 hours.
If BG > 250, take extra ‘R’ insulin STAT!!.
Consume plenty of salty liquids. (sweet liquids if BG < 100).

23. THM-2) DO NOT DELAY IN STARTING Rx: diagnosis does not need a lab
Clinical picture plus
Finger prick BG: >250 mg%
Urine Ketones ++++
 START IV NORMAL SALINE BOLUS!!

24. THM-3) BEWARE OF FALLACIES IN LAB TESTS
High WBC: correlates with ketosis
Raised amylase correlates with ketosis.
Raised BUN dehydration.

25. DKA: INTERPRETING LAB REPORTS
Factitious hyponatremia dilutional.
True serum sodium: Add 1.6 meq for every 100 mg% BG above 100 mg%
S.K+  overestimation of total body K+.
True serum potassium: Lab Potassium value – (0.6x A) (A = 7.4 minus prevailing pH)

26. ECG IN POTASSIUM DISTURBANCES
HYPOKALEMIA:
Flat / inverted T waves, depressed S-T segment, prolonged Q-T interval, U waves.
HYPERKALEMIA:
Peaked T waves, wide QRS, depressed P waves, A-V dissociation

27. DKA: INTERPRETING LAB REPORTS
Ketone bodies B-OH-B & AcAc
Test measures AcAc, but predominant ketone body in DKA is B-OHB.
Initial underestimation, later apparent persistence.
Anion gap: (Na) – (HCo3 + Cl) N: 8-16 meq/L A better measure of the degree of ketosis in DKA

28. THM 4) FLUIDS IN DKA: start early, go slow…..
Volume expansion: 10 cc / kg in 1 hr. Repeat only if shock, hypotension, poor tissue perfusion persist.
Maintenance: evenly over 24 hours.
Deficit: >2 yrs: 3%, 6%, 9% <2 yrs: 5%, 10%, 15%. evenly over hours or more
?Ongoing losses only if excessive (GIT, osmotic losses).

29. FLUIDS IN DKA: AVOID HYPOTONIC FLUIDS
Initial bolus: NS.
BG > mg%: ½ NS + KCL. (continue NS if hypo / hypernatremia, severe hyperosmolarity)
BG < mg%: ½ D5NS + KCL.
BG < 150 mg%: D10 with CRL + KCL.

30. …at outset if < 3.5 meq / L / ECG changes.
THM-5) POTASSIUM: START SOON & REPLACE OVER 2 WKS; EXPECT DROP, MONITOR CLOSELY
Start… after initial bolus fluid & only if urine output (+) & S. K+ <5.5 meq/L.
…at outset if < 3.5 meq / L / ECG changes.
Continue oral potassium till pre-DKA weight.
If > 40 meq / L required (S.K<3.5), use central line & ECG monitoring.
May give part oral by RT.
2/3 as KCl & 1/3 as KPo4 (ideal).

31. POTASSIUM: EXPECT A DROP….
Proteolysis & Glycogenolysis liberation of K+ in the cell
Acidosis, Insulin def draws K+ extracellularly
Polyuria, ketonuria K+ loss from body
With improvement in GFR K+ wash out
With correction of acidosis & provision of insulin K+ moves intracellularly

32. THM-6) INSULIN IN DKA: no urgency, low dose infusion, till acidosis corrected!!
Initial drop in BG due to volume expansion & improved GFR.
More rapid drop in BG with insulin sudden fluid shift ECF to ICF vascular collapse & ?cerebral edema.
Insulin before potassium shift of potassium to ICF acute hypokalemia.

33. INSULIN IN DKA
Short / ultra short acting insulins only.
Bolus unnecessary, unless delay in starting insulin.
Run off 50 cc (insulin adheres to glass & polyvinyl).
Dose @ 0.1 unit / kg / hr.
Double dose if BG fall <50-70 mg%/ hour.
Optimum rate of BG drop= <100mg%/hour.

34. INSULIN IN DKA: TILL CORRECTION OF ACIDOSIS
Keep BG between mg% till ketosis is corrected so that insulin can be continued without risk of:
Osmotic diuresis.
Hypoglycemia.
CRH response.

35. THM-7) BICARBONATE : RARELY IF EVER NEEDED
Over correction of acidosis  true alkalosis.
Acute hypokalemia.
Acute hypernatremia.
Before repletion of RBC 2,3, DPG  shift of O2 dissociation curve to left  tissue hypoxia lactic acidosis.
Paradoxical CNS acidosis ( CO2 crosses B-B-B but HCo3 does not )

36. ADVERSE EFFECTS OF PROFOUND ACIDEMIA
Negative ionotropism
Peripheral vasodilatation
CNS depression
Insulin resistance

37. BICARBONATE IN DKA
When? * pH < * pH < 7.0 after 1 hr of hydration (ADA) * Circulatory failure due to acidosis
* Hyperkalemia with ECG changes
How much? * 1-2 meq / kg as slow infusion over 1-2 hours (never bolus)

38. THM-8) DKA: MONITOR CLOSELY, ALERT FOR CEREBRAL EDEMA
Clinical: every mins.
Accurate I & O record.
BG every hour.
Electrolytes, blood gases, urea, HCT every 2-4 hours.
Serum Na+ should rise with Rx, anion gap should reduce.

39. CEREBRAL EDEMA: WHEN TO SUSPECT?
Vomiting, headache, lethargy, age inappropriate incontinence
Declining / fluctuating mental state, coma,
Dilated, unresponsive, sluggish, unequal pupils,
Sudden hyper / hypotension,
Bradycardia,
Decorticate / decerebrate posturing, papilledema
Unexpected decline in urine output without clinical improvement,
Falling Nacorr to < 130 or Eosm < 275 mOm/kg

40. CEREBRAL EDEMA 1-3% of children with DKA.
1/3 die, 1/3 have permanent CNS sequel.
Accounts for 30% of DKA deaths & 20% of overall childhood diabetes deaths.
Onset during Rx (2-24 hrs), rarely before Rx.

41. THM-9) EMERGENCY RX ON SUSPICION OF CEREBRAL EDEMA
Immediate mannitol: gm/kg IV over 30 mins. Can be repeated every hour till desired response.
Hypertonic saline (3%) 5 ml/kg over 30 min.
Reduce fluid administration rate.
Mechanical hyperventilation (but intubation & hyperventilation to PCo2 < 22 mm Hg ass with poor prognosis).
Dexamethasone?
Furosemide?
Urgent CT to exclude other possibilities.

42. THM-10) COMPLICATIONS ARE IATROGENIC, PREVENTABLE
THERAPEUTIC ERROR
COMPLICATION
Delay in starting IV
Shock, thrombosis
Rapid / hypotonic fluids
Cerebral edema, ARDS
High dose insulin
Hypoglycemia, hypoK+, CE
Injudicious use of HCo3
Alkalosis, hyperNa+, hypoK+, CNS acidosis CE
Delay in giving K+ / Over Rx with K+
Hypokalemia / Hyperkalemia
?Excess chloride
Hyperchloremic acidosis
?Non provision of Po4
2,3 DPG deficiency

44. THANK YOU!!!