Case Presentation

DKA

History PC and
Demographics
30 yo gentleman, resident of
Khuzdar, Balochistan ; was brought
to the ER triage in an unconscious
state, breathing heavily.
After initial assessment, patient was
shifted in resuscitation and attendant
was requested for the history.

History - HOPC
According to the attendant, patient was a k/c of
DM for the past 15 years and was using insulin
three times a day (30 units each), attendant
was unaware of the type of insulin.
Patient had a clinic appointment 1 day ago and
he was requested to get fasting blood glucose
levels done and return to the clinic for further
followup.
After the visit, patient went home and his
condition started deteriorating at night, when
his family rushed him to ER.

History ROS and Past

ROS was remarkable for polyuria and nocturia (23) for many years; weight loss of 30 kg in past 5-6
years.
PMH DM for 15 years.
PSH unremarkable
Family Hx unremarkable
Drugs - Insulin 30 units TID
Social works as a mechanic in Khuzdar,
Balochistan. Married , father of 2.
Addictions non-smoker, non-alcoholic, nonniswar user.

Physical Exam
Patient appeared drowsy and could not converse. His
GCS was 11/15. He had labored breathing.
He had a HR of 120 beats/min, BP of 95/60 mmHg, RR
35/min and a temperature of 36.8C.
Neurological exam disoriented individual, pupils
reactive to light B/L, - Babinski. Sensory and motor
exams were not possible. DTRs normal.
Chest clear to auscultation .
CVS S1, S2
Abdomen soft, non-tender, non-distended, no
visceromegaly.
Extremities weak pulses , no edema noted.

Diagnosis and management

A diagnosis of Diabetic Ketoacidosis was made
and management was started.
After the patient was shifted to resus, 16
gauge cannulas were inserted, and monitoring
equipment was attached to the patient.
1 L N/S was given in bolus and insulin was
injected IV 7 units (0.1ml/kg).
In the meanwhile, ABGs and electrolytes were
sent.
Reflo was done which was 728

Diagnosis and management

Patient was given two more fluid
boluses of N/S and an insulin infusion
at 7 units per hour was started.
Patient was monitored carefully and
blood glucose was checked every
hour to rule out hypoglycemia.

Diagnosis and management

On stabilization of tachycardia and
hypotension, patient was shifted to the
Back region with maintenance fluids.
ABGs showed a pH of 7.25, pCO2 16mmHg,
pO2 of 128 mmHg and HCO3 of 7.1
Electrolytes showed Na 143, K 4.1, Cl 115,
HCO3 7.1. (anion gap 21) .
The labs revealed metabolic acidosis with
increased anion gap.

Diagnosis and management

An admission for special care unit
was requested and patient was
shifted to the ward under care of the
internal medicine team.

Intravenous Sodium Bicarbonate Therapy in Severely Acidotic

Diabetic Ketoacidosis
Ann PharmacotherJuly 2013vol. 47no. 7-8970-975

The use of intravenous bicarbonate in diabetic

ketoacidosis (DKA) may be considered for
patients with a pH less than 6.9 according to the
American Diabetes Association.
To determine whether the use of intravenous
bicarbonate therapy was associated with
improved outcomes in patients with severe DKA
who were seen in the emergency department.

 Conducted from 2007 to 2011 in the

emergency department of a tertiary
teaching hospital.
Adults diagnosed with DKA with an
initial pH less than 7.0 were included.
Patients were stratified into 2 groups
based on receipt of intravenous
bicarbonate.
The primary study outcome was time
to resolution of acidosis, defined as
return to pH greater than 7.2.

 There was no significant difference in time to

resolution of acidosis (8 hours vs 8 hours; p =
0.7) or time to hospital discharge (68 hours vs
61 hours; p = 0.3).
Insulin and fluid requirements in the first 24
hours were significantly higher in patients who
received intravenous bicarbonate compared with
those who did not (100 units vs 86 units; p =
0.04 and 7.6 L vs 7.2 L; p = 0.01, respectively).
Intravenous bicarbonate therapy did not
decrease time to resolution of acidosis or time to
hospital discharge for patients with DKA with an
initial pH less than 7.0.

Thank You !