SYmptoms Treatment and managament of DKA.pptx

DKA treatment and symptoms explained

1. Complicated DKA Musaab Alayob Emergency physician IBHOH

2. Decomplicated DKA A 52-year-old male with a history of type 1 diabetes mellitus for ten years, and HTN. Presents to the emergency department with a two-days history of low-grade fever, sore throat, cough, on and off shortness of breath, nausea, vomited more than 6 times, and worsening polyuria and polydipsia. He reports neglecting his insulin regimen for the past week because of financial issue.

3. History Social History: Denies tobacco use Drinks alcohol occasionally Family History: Unremarkable Medications: Insulin Lisinopril

4. Examination Physical Examination: Conscious, oriented in mild to moderate distress. General: The patient appears dehydrated, with dry mucous membranes. Chest: Bilateral crackles on auscultation and maintaining 90% on room air. ECG: Sinus tachycardia, no ischemic changes. Abdomen: Soft, non-tender, no organomegaly

5. Initial Assessment: Assess the patient's hydration status through clinical signs (dry mucous membranes, poor skin turgor) and IVC; there is no time for laboratory findings to be released to start the management , apart from B glucose, ketone level, and VBG.

6. Vital Signs: Blood pressure: 150/90 mmHg Heart rate: 120 beats per minute Respiratory rate: 25-30 breaths per minute Oxygen saturation (SpO2):90% Temperature: 38.0 °C (100.4 °F)

7. Laboratory Findings Blood glucose: 350 mg/ dL Blood ketones: Positive (high) Venous Blood Gas (ABG): pH: 7.20 pCO2: 25 mmHg (normal: 35-45 mmHg) HCO3: 12 mEq /L (normal: 22-28 mEq /L) Electrolytes: Sodium: 142 mEq /L (normal: 135-145 mEq /L) Potassium: 4.5 mEq /L (normal: 3.5-5.0 mEq /L) Chloride: 100 mEq /L (normal: 98-106 mEq /L) Portable chest X-ray: Bilateral infiltrates suggestive of pulmonary edema.

8. Diagnosis Diabetic ketoacidosis (DKA) with non-cardiogenic pulmonary edema Management: Intravenous fluids with electrolyte replacement Intravenous insulin administration Diuretics Oxygen therapy Close monitoring of vital signs, blood glucose, and electrolytes

9. Fluid Choice Isotonic fluids (normal saline - 0.9% sodium chloride) are typically preferred for initial resuscitation in DKA,. Hypotonic fluids (less concentrated than blood) are generally avoided due to the risk of cerebral edema, especially in some pediatric protocols.

10. Fluid rate The rate of fluid administration will be carefully monitored and adjusted based on the patient's response. Initially, smaller boluses (150-250 mL) might be given with close observation of respiratory effort and oxygen saturation. Urine output will also be monitored as a marker of kidney function and fluid responsiveness.

11. Balancing Needs: The goal is to address dehydration in DKA while avoiding excessive fluid administration that could worsen pulmonary edema. This requires close monitoring of vital signs, blood tests (electrolytes, blood urea nitrogen, creatinine), and chest X-ray (if needed) to assess response to treatment.

12. Regular insulin As per DKA protocol make up a solution of 1 unit per ml. of human soluble insulin (e.g. Actrapid ) by adding 50 units (0.5 ml) insulin to 50 ml 0.9% saline in a syringe pump. Run the solution at 0.1 units/kg/hour (0.1ml/kg/hour)

13. Diuretics If fluid overload contributes to pulmonary edema, diuretics may be used cautiously to promote diuresis and reduce the lung congestion. The doctor will determine the specific type and dosage of diuretics based on the patient's needs.

14. Non invasive ventilation NIV NIV can improve oxygenation, reduce the work of breathing, and potentially lessen the need for invasive mechanical ventilation. When to Consider NIV: Moderate respiratory distress with increasing breathing work. Falling oxygen saturation despite receiving supplemental oxygen. Altered mental status due to respiratory acidosis.

15. Discussion: This case demonstrates a complicated DKA – pulmonary edema. The exact mechanism is not fully understood but likely involves factors like increased capillary permeabi lity due to ketones and acidosis, pneumonia , and potential pre-existing cardiac dysfunction .

16. Hospital Course: The patient was admitted to the intensive care unit (ICU) for close monitoring and aggressive management of DKA. Intravenous fluids were cautiously administered to address dehydration while avoiding fluid overload that could worsen pulmonary edema. Insulin therapy was initiated to correct hyperglycemia and improve metabolic acidosis. Oxygen therapy improved his oxygen saturation.

17. Over the next 48 hours, the patient's blood glucose levels normalized, his metabolic acidosis resolved, and his respiratory distress improved significantly. Chest X-ray showed clearing of the pulmonary infiltrates. He was subsequently transferred to a regular ward for further recovery and diabetes education.

18. Conclusion The management of DKA with pulmonary edema is complex and requires the expert management. Early diagnosis and prompt management are crucial for a favorable outcome in DKA with pulmonary edema. This case highlights the importance of maintaining good glycemic control in diabetic patients and seeking medical attention promptly when symptoms of DKA arise.

19. Resources Kabashneh , S.  et al.  (2020)  Diabetic ketoacidosis complicated by a brain death ,  Cureus . Available at: https:// www.ncbi.nlm.nih.gov / pmc /articles/PMC7389190/ (Accessed: 05 May 2024).  Nwankwo, C.I.  et al.  (2023)  Diabetic ketoacidosis complicated by thrombotic thrombocytopenic purpura: A rare association ,  Cureus . Available at: https:// www.ncbi.nlm.nih.gov / pmc /articles/PMC10202223/ (Accessed: 05 May 2024).  Majid, A. and Wheeler, B.J. (2017)  Severe diabetic ketoacidosis complicated by hypocapnic seizure ,  EDM Case Reports . Available at: https:// edm.bioscientifica.com /view/journals/ edm /2017/1/EDM17-0048.xml (Accessed: 05 May 2024). 

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