Diabetic Ketoacidosis with Pneumonia

SUBMITTED BY: ROLL NO: UNIVERSITY ROLL NO: Anand Singh Brar 11 01320059010

Case Details
NAME : MANJU AGE : 14 YRS SEX : FEMALE MRD NO. : 77581 DEPARTMENT : MEDICINE DATE OF ADMISSION : 3.8.12 Patient is a case of Type 1 DM diagnosed in April 2012 and was on Insulin Mixtard(40U, 26U) and Metformin 500mg BD CHIEF COMPLAINTS 1) Pain Abdomen on 3.8.12 2) Vomiting 3) Breathlessness 4) Cough with sputum HISTORY OF PRESENTING ILLNESS Patient was apparently well 4 days back when she missed her medication on 2.8.12 and developed 1) Pain abdomen 2) 3 episodes of vomiting 3) breathlessness, cough with sputum EXAMINATION The general condition was poor and patient was dehydrated. Pallor present. Body weight = 30 kg B.P. - 118/60 mm of Hg Pulse 148 beats per min Respiratory system Pt. dyspnoeic, Nonvesicular breath sounds on R. side heard CVS, CNS, P/A Within Normal Limits INVESTIGATIONS Hb 8.7 gm/dl TLC 23,400/mm3(N: 84) RBS Highly elevated Ketones 4+ Serum Electrolytes Sodium 123 mmol/L Potassium 4.1 mmol/L Arterial Blood Gas analysis pH 7.096 pC02 14.2 mmHg HCO3- 4.2 mmol/L KFT Urea 22 mg/dl Creatinine 0.4 mg/dl Chest X-ray Right sided, multiple opacities ECG normal

Treatment & RBS monitoring

Oxygen inhalation at 3-4 L/min IV Fluids(1L in first hour, reducing based on volume status) Human ACTRAPID(Regular Insulin) Monocef (Ceftriaxone) Azithral (Azithromycin) Rantac (Ranitidine) Perinorm (Metoclopramide) Sodium Bicarbonate

Time (From 3.8.12 to 5.8.12) 9.30 am 10.30 am 11.30 am 12.30 pm

Random Blood Sugar High 419 350 278

Ketone in urine

Insulin given iv

IV fluids (NS- normal saline, DNS- 5% dextrose + 0.5 normal saline) NS (30ml/hr)

4+ 4+ 4+ 3+

3 U stat 3 U/hr

1.30 pm
3.30 pm 5.30 pm 6.30 pm 7.30 pm 8.30 pm 10.00 pm 12 am 3.30 am 11.30 am 3 pm 6 pm 7.30 pm 8.30 pm 1 am 5 am 7 am 11 am

140
122 311 510 411 331 162 360 High 429 High 166 363 413 514 302 202 100

3+
3+

1 U/hr
3 U/hr

DNS(100ml/hr)
DNS(30ml/hr) DNS(50ml/hr) DNS(30ml/hr) DNS(50ml/hr) NS(30ml/hr) DNS

3+

1 U/hr

3+ 3+ 1+ -ve

1 U/hr 5 U/hr 3 U stat 3 U/hr 1 U/hr

Patient disconnected drip 3 U/hr 1 U/hr 2 U/hr 1 U/hr NS NS DNS(20ml/hr) NS(10ml/hr)

Treatment
Sno 1 2 Date of case 3.8.12 3.8.12 Drug name IV fluids Dose As per need Started on 3.8.12 Stopped on Freq/ day As per chart BD OD OD BD BD 1 Route iv iv Outcome Patient stable and hydrated Blood sugar declines adequately Condition improving TLC - 9200/mm3 N:73 Good. No complaint Good. No repeat episode Patient stable, serum HCO3awaited Human As per 3.8.12 ACTRAPID RBS chart (Regular Insulin) Monocef Azithromycin Azithral Rantac Perinorm Sodium Bicarbonate 1 gm 500mg 500mg 1 amp 1 amp 3.8.12 3.8.12 3.8.12 3.8.12 3.8.12

3 4 5 6 7 8

3.8.12 3.8.12 3.8.12 3.8.12 3.8.12 3.8.12

9.8.12 3.8.12 5.8.12 9.8.12 3.8.12 3.8.12

iv iv oral iv iv iv

15 amp 3.8.12 in NS(1L/hr)

Discussion
Therapeutic problem dealt with adequately in this case. Choice of drugs Appropriate because, IV fluids were given to correct dehydration. Regular Insulin(as bolus and as infusion) was given as per indications(0.1 U/kg bolus and 0.1 U/kg/hr infusion) Azithromycin and Ceftriaxone were given to combat pneumonia. Ranitidine was used to prevent stress ulcers. Metoclopramide was used for symptomatic treatment of vomiting. Sodium bicarbonate was given to correct the electrolyte imbalance. In addition to the above approach, I would have added 10-20 mEq/hr KCl to the iv fluid after 4 hours of starting insulin. Because, with insulin therapy, K+ is driven intracellularly and dangerous hypokalemia can occur. investigated serum Phosphate. If it was in the low-normal range, 5-10 ml/hr of sodium/phosphate infusion could be started. kept the patient in ICU cubicle and monitored closely.