CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
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Transcript of CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
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CASE PRESENTATION ON
Diabetic Ketoacidosis By, Aromal Satheesh II PHARM-D
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Name: xyz
Age: 11yrs. Sex: female Weight: 19 kg Unit: pediatric-II
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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
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PMHX: NS
Allergy: NKA
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DIABETIC KETOACIDOSIS
PROVISIONAL DIAGNOSIS:
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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
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CNS – Lethargic , Adv: ophthalmology opinion
Report: Fundus normal- both eyes
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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…
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MICROBIOLOGY
Urine ketones +++ Albumin : nil Sugar : 2% Pus cells: 2-3 Epithelial cells: 1-2
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Rx: IVF NS bolus @ 20 ml/ kg over 1 hr.
400ml followed by ½ NS @ 117 ml/ hr
Actrapid insulin iv 5 units qid
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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
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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
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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
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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
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IVF- stopped Inj Actrapid 10 units SC qid
CBG 8:30 am – 106 mg/ dl 9:30 am -186 mg/dl
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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
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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
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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
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No fresh complaints No dehydration Adv: Stop Actrapid Start Mixtard insulin 25- 0-15 from tomorrow morning: 15-0-15
Day 6 & 7
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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
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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
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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
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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
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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
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Adv: Discharge on insulin 25-0-15 units Follow up regularly
Day 12
CBG12MN- 315mg/dl6am- 102 mg/dl
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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
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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
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Subjective
fever
polyuria polydipsia &
polyphagia
Objective
Urine ketones +++Urine sugar : 2%Elevated RBS:
454mg/dl (70-150)
PHARMACEUTICAL CARE PLAN
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DIABETIC KETOACIDOSIS
FINAL DIAGNOSIS
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Fluid & electrolyte balanceCorrection of hyperglycemiaTo prevent hypokalemia & cerebral edema
GOALS OF THERAPY
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IV Fluids
Insulin preparations: Rapid acting- Lispro , Aspart ,
Glulisine Intermediate acting – NPH Long acting – Glargine , Detemir
TREATMENT OPTIONS
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Sign & symptoms of dehydration was reduced by Day 2
Urine ketones were absent by Day 2
GOALS ACHIEVED
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Blood Glucose levelsBody weightElectrolytes Urine ketone & urine sugarSymptoms of hyperglycemiaSymptoms of cerebral edemaDiet habits
MONITORING PARAMETERS
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Bicarbonate level not monitored
PROBLEMS IDENTIFIED
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ABOUT THE DISEASE sign & symptoms complications
ABOUT THE MEDICATION purpose & dose importance of medication adherence possible adverse effects
PATIENT COUNSELLING
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ABOUT LIFESTYLE MODIFICATION Diet Exercise
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Thank You