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Diabetic Ketoacidosis

Disclaimer

  • Modern medical science based case discussion for doctors & hospitals.

Case

  • A 48 Yr patient comes with abdominal pain, nausea and vomiting, K/C/o Diabetes mellitus

  • Dry mucous membranes, confused

  • RBS 450

  • Urinary Ketones +ve

    • (If RBS >= 200, do dipstick test to rule out the hyperglycemia or Diabetic Ketoacidosis)


Diagnosis

  • Hyperglycemia (250-800)

  • Low Bicarb < 18

  • Low pH < 7.3

  • High Anion Gap Acidosis

  • Increased Osmolality

  • Increased BHB (Beta-hydroxybutyrate), Serum Ketones

  • Urinary Ketones

Cause

  • Non-compliance with insulin

  • Infection

  • Type 1 > Type 2

Mechanism

  • Stress – Sugary Hormones (cortisol, Glucagon, Growth Hormone, Catecholamines)

  • Insulin deficiency

  • Sugar is high

  • Body thinks that we are starving

  • Starts making ketones for energy

  • Sugar causes osmotic diuresis

  • Intracellular dehydration – 6 lit deficit

  • Pseudohyponatremia

  • Hypokalemia

What will you do?

  • Admit in ICU. Monitor, RBS & SpO2

  • Don't ever give Insulin in this case!!!

  • First, We will give IV Fluids – BSS/NS

  • Send for ABG, Blood Chemistry, ECG, CBC

  • And… Wait for Potassium

    • NO INSULIN till Potassium is verified on paper from tests

    • Once you know that K is > 3.5 then only start insulin 0.1 U/kg

      • 70 kg man = 7 Units/hr

    • Fluid Resuscitation

      • 20 ml/kg isotonic Crystalloid

      • ECG – Potassium

  • Search for the Cause

    • Did he skip insulin?

    • Any infection

  • Target of Insulin Infusion

    • Is not correction of Hyperglycemia

    • It is correction of Acidosis HCO3 > 15, pH > 7.3 & Anion Gap < 12

    • If RBS < 250, add Dextrose to Fluids

  • Treatment of Acidosis?

    • Yes, you can give Sodabicarb

    • Only if patient is in cardiac arrest, severe Hyperkalemia, or severe hypotension

  • What about Intubation?

    • Please don't Intubate, RR 30

    • Senior most expert can decide and Intubate within few seconds in case it is unavoidable

  • Check Mental status hourly

    • If altered Sensorium, consider cerebral edema

    • Stop IV, Elevate Head end

    • Osmotic Diuresis (Mannitol)

Summary

  • Start with Fluid NS

  • First Correct Potassium

  • Insulin till Acidosis Resolves

  • No Sodabicarb

  • Watch for Cerebral Edema


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