Diabetic ketoacidosis

Lee Lay Chin

Case
Name Age Gender Race Height Weight BMI DoA DoD : MH : 66 : Male : Malay : 158cm : 52kg : 20.8 : 7.4.2008 : 14.4.2008

Presenting complaint
Fever X 3/7 Vomited a few times Noted by family the glucometer result was too high

History of presenting complaint

Not taking OHA X 3/7 Lethargic and bed bound X 3/7 Scrotal area was swollen, red, macerated for a few days Blurred vision for quite some times.

Past Medical History & Drug History

Type 2 DM (10 years)
T. Gliclazide (Diamicron MR) 120mg OM T. Metformin 1g tds HbA1C : Nov 2007 : 11.5

Hypertension (8 years)
T. Perindopril 4mg od T. Amlodipine 5mg od

Social / Family History

Staying with family in Klang Brother has Type 2 DM

Review of System
BP : 104/56 RR : 88 PR : 24 T : 37.8oC SPO2 : 91% Dstix : 24.6mmol/L (SC actrapid 16 units stat) Lung : Clear Abdomen : Soft & non tender CVS : DRNM

Impression / Diagnosis
Diabetic ketoacidosis (DKA) Scrotal cellulitis

Definition
Is a complication of diabetes Occurs when the body uses fat as fuel source instead of glucose because of no insulin or not enough insulin Fat is broken down, ketone (acid) is formed and built up in urine.

Lab Investigations

Management, Clinical Progress & Pharmaceutical Care plans

Management of DKA
1. 2. 3. 4. 5. 6. Fluid replacement Regular insulin (IV/IM) Treat underlying condition Measure capillary glucose (every 1-2h) Measure electrolytes & anion gap (every 4h for 24h) Monitor BP, pulse, respiration, mental status, I/O (every 14h) Replace K Continue above measure until patient is stable (glucose goal is 8-14mmol/L) Administer intermediate / long acting insulin as soon as patient is eating.

7. 8.
11.

Clinical progress: Day 1

Low BP (104/56) High T (37.8) High glucose (24.6mmol/L) Urine ketone: 2+ Patient dehydrated. Scrotal: Red, marcerated Groin: erythematous + blister Fundoscope:
Dense cataract Diabetic retinopathy Plan (4pm): Withhold anti HPT IV ceftriaxone 2g stat & od IV drip 4 pints/24h + 1g KCl in alternate pint IV insulin 5 units/h (Change to IVD D5% once dxt<12, NS if dxt>12) 2 hourly dxt Genital swab (C&S) NS dressing on T. aspirin 150mg od

Metabolic acidosis
pH : 7.3 pCO2: 28 pO2: 61 HCO3 : 14.5

PCI (Day 1)
PCI Pharmacist Recommendation Outcome
Time Drip should be NS 1 L in 1 hour, 2 hour, 4,6,and 8 Glucose (mmol/L)

Management of DKA
The fluid replacement regimen was not appropriate :IV 4 pint within 24 hours.

330pm 24.6 6pm 8pm 20.7 13.4

10pm
Possibility to change IVD fluid with the change of glucose level. Change to IVD D5% when glucose level

11.3

reach 14 mmol/L (sarawak handbook) Monitoring of ketone in urine and ABG.

IVD changed to IVD5 at 8pm.

Ketone present lesser till absent in urine and ABG did not so acidosis

UFEME
Day Bacteria Glucose Ketones pH Protein RBC Count Leucocytes 1 Negative 2 Negative 3 Negative 4-8

4+ 2+
5

2+ 2+
5

1+ 1+
6

1+ 1+
Negative 1.015 Negative Negative Yellow

2+
Negative

2+
Negative

3+
1.005 Negative Negative Yellow

3+
1.005 Negative Negative Yellow

Other cells a) SG b) UBG c) Bil d) Colour

Arterial Blood Gas

Day
pH

1
7.3

3
7.3

4-8

pCO2
pO2 HCO3

28
61 14.5

31.5
97 17.2

Input / Output chart

Day 1 2 3 4 5 6 7

Input

1000

3340

955

1265

1090

695

700

Output

600

1150

1200

900

1650

1700

1500

Balance

+400

+2190

-245

+1365 -560

-1005 -800

PCI (Day 1)
PCI Pharmacist Recommendation Outcome No paracetamol is given. Antibiotics remained unchanged. TWBC normalised on D3. No spiking temperature Scrotal swelling reduced.

Management of T. paracetamol 1g stat and prn scrotal cellulitis Monitor Temperature, WBC count.
Review antibiotics used in cellulitis

Inappropriate antibiotic for the treatment of scrotal

IV ceftriaxone 2g od had been given.

Sanford 2007 (pg18, 86, 92): Early mild disease T. Trimetoprim sulfamethoxazole double strength (160TMP/800SMX) 2 tab bd with T. Rifampin 300mg bd.
Severe disease IV Imipenem (1g IV od) / IV meropenem (0.5g IV qid) / IV ertapenem (0.5-1g tds) Plus IV / PO linezolid 600mg bd / IV vancomycin (based on weight)

Full Blood Count

Day TWBC Hb RBC HCT 1 11.6 12.3 4.21 38.0% 2 3 7.8 11.4 3.70 33.5% 181.0 4-8

Platelet 187.0

Vital Signs
Day BP T 1
104/ 58

2
123/ 71

3
129/ 60

4
150/ 79

5
139/ 80

6
121/ 76

7
142/ 72

8
139/ 73

37.8

37

37

37

37

37

37

37

RR
PR

22
80

20
104

20
80

20
100

20
91

20
91

20
91

20
100

PCI (Day 1)
PCI Pharmacist Recommendation Outcome

Retinopathy screening & treatment

Patient: Dense cataract Diabetic retinopathy

ADA 2007: Patient was referred to Optimal glycemic control ophthalmologist. Optimal BP control Refer to ophthalmologist. Perform examination annually by ophthalmologist. (Examinations will be required more frequently if retinopathy is progressing)

Clinical progress: Day 2

BP: 123/71 Dry tongue, patient dehydrated Scrotal & groin: red, inflammed reduced
Time 2am 4am 6am 8am 10am 1220pm 4pm 6pm 820pm 10pm 12am 6.3 7.2 9.2 12.6 14.4 12.3 8.4 6.7 5.8 6.2 3.3

Glucose (mmol/L)

Plan: Increase to 5 pints NS/24h IV insulin 2 units/h IV Augmentin 1.2g stat and tds 2 hourly dxt

Withold insulin infusion

PCI (Day 2)
PCI Pharmacist Recommendation Monitor glucose level. Withhold insulin infusion IV D50 50 cc stat Outcome Insulin infusion was withhold. No glucose was given

Prevention of hypoglycemia
Patients glucose level dropped to 3.3mmol/L.

PCI (Day 2)
PCI Pharmacist Recommendation ADA 2007: For those over 40 years old, Statin therapy to achieve an LDL reduction of 30-40% regardless of baseline LDL levels. Can be Initiated with: a) Lovastatin (20mg ON) b) Simvastatin (10-20mg ON) c) Atorvastatin (10-20mg od) If statins were to be initiated, to Baseline was done do LFT, AST and ALT baseline and to do as and 3 monthly outpatient in clinic. Outcome initiated with lovastatin 20 mg on.

Riview of Lipid management

Liver Profile
Day Albumin T.Bilirubin T.Protein 1 2 23 9 72 3-8

ALP
ALT AST

140
57 79

Lipid Profile
Date Lipid profile 8.1.2008 Results (mmol/L)

T.Chol (<5.7mmol/L) 6.1

TG (< 1.7mmol/L)
HDL (> 1.7mmol/L) LDL (<3.9mmol/L)

2.0
0.5 3.7

Clinical progress: Day 3

Imp: Fluid overload Not sleeping well yesterday Groin: still erythematous with blister
Time 12am 1am 4am 6am 8am 10am 12pm 2pm 640pm 10pm Glucose (mmol/L) 4.4 5.1 4.8 4.3 3.9 4.7 4.3 7.2 8.3 7.1

IVD 2 pints D5% Start IV insulin 0.5units / h GM 2 hourly Reduce drip to 1 pint D5% Overlap with sc insulin SC actrapid (10 units tds) SC insulatard (14 units ON) Withhold insulin infusion Continue daily dressing

PCI (Day 3)
PCI Pharmacist Recommendation Outcome Patient was started with a) SC actrapid (10 units tds) b) SC insulatard (14 units ON) Total: 44 units/day (0.85 units/kg/day)

Review of Oral hypoglycemic agent

Pharmacotherapy handbook: Insulin therapy Patient HbA1C was 15.1 (0.7 2.5 (11.5 - Nov 2007) units/kg/day) Can be started Patient was on maximum dose on basal bolus of OHA insulin regimen a) T. Gliclazide MR 120mg OM Perform HbA1C b) T. Metformin 1g tds test in 3 months time. Patients CLcr trend: D1: 37.0mL/min D2: 39.1mL/min

Renal Profile
Day Urea Na K Cl Ca Mg PO4SrCr ClCr Uric acid 128 37.0 0.31 121 39.1 400 110 43.0 111 42.6 1 7.8 138.3 4.6 103.8 2 4.6 142.9 4.31 108.2 1.82 3 4.5 140.2 3.59 111.1 4-6 7 3.0 140.5 3.55 107.1 8

Clinical progress: Day 4

C&S: Staphylococcus spp Taking orally (not much) Time 1225am 2am 4am 6am 4pm 8pm Glucose (mmol/L) 6.6 6.5 6.6 5.6 5.3 6.7 Date Sample Micro-organism Sensitivity Plan: Continue IV antibiotics Daily dressing with NS GM 4 hourly Off IV D5% Reduce dose: SC actrapid 8 units tds 11.1.11 7.1.11 Genital swab staphylococcus spp. Erythromycin, gentamicin, Penicillin oxacillin

Date sampling

1030pm

6.4

Resistant

PCI (Day 4)
PCI Pharmacist Recommendation Monitor ABG daily until metabolic acidosis resolved. Outcome Only monitored till day 3 Patient was not tachypnoeic.

ABG monitoring Patients ABG was monitored on day 1 and 3. ABG trend Day pH pCO2 1 7.3 28 3 7.3 31.5

pO2

61

97
17.2

HCO3 14.5

Clinical progress: Day 5

Sleep well Afebrile Plan (8am): Continue medications

Time
430am 8am 11am 530pm

Glucose (mmol/L)
9.8 10.3 20.1 16.7

PCI (Day 5)
PCI Pharmacist Recommendation Outcome Actrapid was increase d to 14 ii tds.

Glucose level was high.

Assess patient on present of

Time 430am 8am 11am 530pm

Glucose (mmol/L) 8.0 10.3 20.1 16.7

hypoglycemic symptoms Increase dose of: Insulatard from 14 to 16 units. Actrapid from 8 to 14 units. Novo Nordisk Diabetes Care Services leaflet: Blood Glucose Level Above Target Value Add

Up to 1 mmol/L
1 to 2 mmol/L > 2 mmol/L

2iu
4iu 6iu

Clinical progress: Day 6

GM 8am: 13.7 GM trend (Day 5) 9.8/20.1/16.7/9.3 Afebrile
Time 12am 4am 8am 1220pm 6pm 1030pm 1140pm Glucose (mmol/L) 9.3 6.4 13.7 9.9 10.4 5.1 5.1

Plan: Increase dose SC actrapid 14 unit tds GM monitor 4 hourly

Clinical progress: Day 7

Afebrile Respond to Antibiotics for scrotal cellulitis
Time 2am 6am 8am 1240am 6pm 1030pm Glucose (mmol/L) 5.2 6.4 8.0 6.0 6.1 4.9

Plan: GM monitoring qid Increase dose SC insulatard 16 units ON GM monitor 4 hourly Restart T. Amlodipine 5mg od Aqueous cream prn at scrotal area.

PCI (Day 8)
PCI Pharmacist Recommendation Patient have DM and renal insufficiency, give anti-hypertensive a) T. perindopril 4mg od ADA 2007 recommend: ACEI for DM patients > 55 years old at high risk of CVD. ACEI may be superior to dihydropyridine CCB in reducing cardiovascular events. Outcome

Management of hypertension T. amlodipine restarted on D7

Patient was known to have bilateral stenosis.

Patient BP trend in ward

Patients CLcr in ward ACEI and ARB delay progression to

macroalbuminuria.

Clinical progress: Day 8

Patient slept well. Afebrile
Time 8am Glucose (mmol/L) 5.6

Plan: Off IV antibiotics Start oral Augmentin 625mg bd Discharge today

1230pm

4.6

Ward medications
Drug Day start Day stop

IV Ceftriaxone 2g od
IV Amoxycillin / clavulanate potassium Tablet aspirin 150mg od Tablet lovastatin 20 mg on Tablet amlodipine 5mg od SC actrapid 16 units stat SC insulatard 14 units ON SC actrapid 10 units tds SC actrapid 8 units tds SC actrapid 14 units tds SC insulatard 16 units ON

1
2 1 3 7 1 3 3 4 7 7

8
8 8 8 8 1 7 4 7 8 8

Cream aqueous prn

Discharge Medications
T. Aspirin 150mg od T. lovastatin 20 mg on SC Insulatard 16 units ON SC Actrapid 14 units tds T. Amlodipine 5mg od T. Amoxycillin / clavulanic acid 625mg bd X 3/7

References
Malaysian Practice guideline (2004):
Management of Type 2 Diabetes Mellitus Diabetic nephropathy

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH000136 3/ American Diabetes Association (2007): Standards of Medical Care in Diabetes.Diabetes Care 2007;30:S4-41 BSPED Recommended DKA Guidelines. JNC 7 hypertension guideline Sanford guide to antimicrobial therapy Diabetic ketoacidosis, David E. Trachtenbarg, MD. American family physician. DiPiro,J.TTalbert,R.L. Yee,G.C.et al (2005).Pharmacotherapy, A pathophysiology Approach. 6th Edition,Appleton & Lange Harrisons principle of internal medicine

THANK YOU