A 37-year-old female presented to the emergency room with abdominal pain, shortness of breath, chest pain, and palpitations. She had a history of gestational diabetes. Laboratory tests confirmed diabetic ketoacidosis with high blood glucose, ketones, low pH, and high anion gap. She was treated according to guidelines with IV fluids, insulin, electrolyte replacement, and antibiotics. Over four days in the ICU and medical ward, her condition improved as her acidosis, electrolytes, blood glucose, and vital signs normalized.

1. DIABETIC KETOACIDOSIS
CASE PRESENTATION ICU ,MEDICAL
WARD ROTATION 2.
Presented by : Walaa Aljuaid , Manal Alosaimi

2. OUTLINES :
• THE CASE .
• WHAT IS THE DKA
• DEFINITION
• CAUSES
• INCIDENCE AND PREVALENCE
• DIAGNOSIS
• COMPLICATION
• TREATMENT
• INTERVENTION

3. THE CASE :
▸ N is a 37 years old female , come to the ER
complaining of abdominal pain, shortness of
breath, chest pain and palpitation .
ER

4. HISTORY OF PRESENT ILLNESS
▸ She has had 2 times Gestational diabetes 4
years ago in her first pregnant and 1 years ago
in her second pregnant .
▸ Family history : Unknown
▸ Allergy : No Kind of Allergy .
▸ Medication history : did not mention .
ER

5. REVIEW OF SYSTEMS :
‣ Eyes: normal
‣ Mental status: conscious .
‣ Respiratory system: Normal sounds
‣ Cardiovascular system: S1+S2
‣ Chest wall & breast: No any diseases
‣ Abdomen: soft and lax .
‣ Extremities : No any diseases.
ER

6. VITAL SIGN ON ADMISSION
▸ Normal Ranges :
▸ Patient Vital sign :
Temperature PR RR O saturation BP
36-37 60-100 16-20 > 96% 120/80
Temperature PR RR O saturation BP
37.3 160 40 98% 130/80
ER

7. LAB TESTS:
▸ Normal Blood Gases :
▸ Patient’s Blood Gases :
PH PCO2 PO2
7.35-7.45 32-48 83-108
PH PCO2 PO2
7.002 16.3 63
ER

8. ▸ Glucose ++++
▸ Ketones +++
URINE ANALYSIS :
LAB RESULTS :
Glucose mg/dl K Na Cl
70-119 3.5-5.3 135-153 98-110
Normal Ranges
Glucose mg/dl K Na Cl
417 4.99 136 99
Patient’s Ranges
ER

9. CBC :
Normal Ranges
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
12.06 5.5 14
Patient’s Ranges
ER

10. FINAL DIAGNOSIS:
DIABETIC KETOACIDOSIS

11. WHAT IS THE DIABETIC KETOACIDOSIS ( DKA ) ?
▸ DKA is a life-threatening condition that develops when
cells in the body are unable to get the glucose they need
for energy because deficiency of the insulin.
▸ Without enough insulin, the body begins to break down
fat as fuel.
▸ This process produces a buildup of acids in the
bloodstream called ketones, eventually leading to diabetic
ketoacidosis if untreated.

12. CAUSES :
▸ Severe infection or other illness, leading to severely
dehydration due to decrease of the insulin levels.
▸ It can occur in people who have little or no insulin in their
bodies ( Diabetes type 1) .
▸ When the blood sugar levels are high ( diabetes type 2 ) .
Our Patient
Our Patient

13. INCIDENCE AND PREVALENCE :
▸ Ranking of countries according to frequency of DKA
demonstrated that the highest frequencies were seen in
the United Arab Emirates (80%), Romania (67%), Taiwan
(65%) and Saudi Arabia (59%) and the lowest in Sweden
(14%), Canada (18.6%), Finland (22%) and Hungary
(23%).

14. DIAGNOSIS
▸ Notice symptoms such as : ( Drowsiness , rapid
breathing ,fruity breath odor ,loss of appetite, belly pain .. )
▸ Laboratory tests, including blood and urine tests, are used
to confirm a diagnosis of diabetic ketoacidosis.
▸ High blood glucose level .
▸ Glucose and Ketones body in Urine .
▸ Acidosis ( Ph low than 7.30 )
IN OUR PATIENT

15. COMPLICATION:
▸ Hypokalaemia : This is one of the main causes of deaths in
adults with diabetic ketoacidosis.
▸ Hypokalaemia can cause a number of problems :
▸ Weakness and fatigue
▸ Muscle cramps
▸ Breathing difficulties
▸ Arrhythmia.

16. ▸ Acute kidney failure
▸ Cerebral edema
▸ Acute respiratory distress syndrome

17. TREATMENT :
▸ Treatment goals of DKA management include optimization
of :
▸ 1) volume status .
▸ 2) hyperglycemia and ketoacidosis .
▸ 3) electrolyte abnormalities .
▸ 4) correct Anion Gap
ANION GAP IS THE DIFFERENCE BETWEEN PRIMARY MEASURED CATIONS (SODIUM NA+ AND POTASSIUM K
+)

18. ▸ Several important steps should be followed in the early
stages of DKA management:
▸ 1-Collect blood for metabolic profile before initiation of
intravenous fluids .
▸ 2-Infuse 1 L of 0.9% sodium chloride over 1 hour after
drawing initial blood samples.
▸ 3-Ensure potassium level of >3.3 mEq/L before initiation
of insulin therapy .
▸ 4-Initiate insulin therapy only when steps 1–3 are
executed.

19. BACK TO THE
CASE :

20. FIRST DAY :
▸ In the ER patient was looks sick complaining of her
stomach and shortness of breath , dehydration .
▸ Medications :
Drug name Dose frequency Route of
administration
Normal
saline
500 mg - IV
Meteclopro
mide
10 mg - IV
Ranitidine 50 mg - IV
Pethidine 50 mg - IM
ER

21. ASSESSMENT :
▸ Patient dose not know that she has infection or DM ,
because her previous doctor say that she is okay and do
not has any DM .
▸ In the ER room they give her NS for dehydration ,
Pethidine for ( Pain and breathing difficulties ) ,
Meticlopromide for Vomiting and Ranitidine for Stomach
pain then she transfer to the ICU to complete
management .
ER

22. AT ICU :
▸ Her AG was 33
▸ Glucose level was high
▸ +++++ Ketones body
▸ PH = 7.006
▸ SEVER DKA
NORMAL RANGE = 10-12
ICU

23. MEDICATION AT ICU :
Drug name Dose frequency Route of
administration
Normal saline 250 mg Q 1hr IV
Dextrose
Solution + NS
250 mg Q 1 hr IV
Regular Insulin 7 IU Q 1 hr IV
Propranolol 10 mg TID P.O
Ceftriaxone 1 g BID IV
Enoxaparine 4000 IU OD SC
Omeprazole 40 mg OD IV
Sodium
bicarbonate
100 mEq immediately IV
Kcl 7.5 mEq Q1hr IV
Paracetamol 1000 mg OD IV
ICU

24. ASSESSMENT :
▸ Giving NS if blood glucose > 200
▸ Giving D5 NS if BG <200
▸ Giving D50 50 ml if BG < 70
▸ Use Regular insulin 7 IU to decrease BG .
▸ Give Kcl if K level 3.5 - 5 , hold if it > 5.3 , less than 3.5
increase the dose into 30 mEq and hold insulin .
▸ Propranolol To reduce blood pressure .
To Control blood Sugar .
To Prevent
hypo-hyperkalemia
ICU

25. ▸ Using of Sodium bicarbonate to reduce PH
▸ Antibacterial Ceftrixone as empiric antibacterial to treat
the infection which is community acquired pneumonia .
▸ She was vomiting , but there is no cough
▸ She was slightly febrile and return a febrile after
paracetamol injection .
ICU

26. SECOND DAY :
▸ They keep using the same ICU medication exception
discontinued paracetamol .
▸ Patient is improving
▸ AG start to decrease into 18
▸ Patient Vital sign :
Temperature PR RR O saturation BP
37 120 20 96% 109/78
ICU

27. PH PCO2 PO2
7.11 19.2 34.9
▸ Patient’s Blood Gases :
Glucose mg/dl K Na Cl
178 3.2 142 110
▸ Patient’s Blood Gases :
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
6.42 5.5 12.3
▸ CBC :
ICU
IMPROVE

28. ASSESSMENT :
▸ Patient is improving according to her lab results and vital
signs .
▸ They stop insulin while giving her Kcl because Insulin
administration and correction of acidemia and
hyperosmolality drive potassium intracellularly, resulting in
hypokalemia
▸ No Vomiting or abdominal pain or cough or fever .
ICU

29. THIRD DAY
▸ They keep using the same ICU medication and the patient
shifted to the regular ward .
▸ Patient is improving
▸ AG decrease into 10
▸ Patient Vital sign :
Temperature PR RR O saturation BP
37 90 20 96% 109/78
DECREASED INTO NORMAL LEVELS
FMW

30. MEDICATION AT FMW :
Drug name Dose frequency Route of
administration
Normal saline 250 mg Q 1hr IV
Dextrose
Solution + NS
250 mg Q 1 hr IV
Regular Insulin 7 IU Q 1 hr IV
Propranolol 10 mg TID P.O
Ceftriaxone 1 g BID IV
Enoxaparine 4000 IU OD SC
Omeprazole 40 mg OD IV
Insulin Glulisin 1 mEQ TID S.C
Kcl 7.5 mEq Q1hr IV
Ventoline 100 mpg BID 2 puffs
FMW

31. PH PCO2 PO2
7.5 23.3 62.7
▸ Patient’s Blood Gases :
Glucose mg/dl K Na Cl
169 5.6 140 110
▸ Patient’s Blood Gases :
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4.3 5.5 12.5
▸ CBC :
FMW
IMPROVE

32. ASSESSMENT :
▸ Patient is improving according to her lab results, CBC and
vital signs .
▸ They stop Kcl and give her Ventoline 2 puffs , because its side
effect include hypokalemia No Vomiting or abdominal pain
or cough or fever .
▸ Anion gap Measured 2 times in the 2 times results were
normal so they shifted into Female Medical Word .
▸ Starting SC insulin beside regular insulin to control diabetes .
FMW

33. FOURTH DAY :
▸ They keep using the same medication except Sodium
bicarbonate > discontinue
▸ Patient is improving
▸ Patient Vital sign :
Temperature PR RR O saturation BP
37 98 18 98% 119/80
FMW
IMPROVE

34. PH PCO2 PO2
7.4 35 95
▸ Patient’s Blood Gases :
Glucose mg/dl K Na Cl
124 4.99 138 100
▸ Patient’s Blood Gases :
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4.3 5.5 12.5
▸ CBC :
FMW
IMPROVE

35. ASSESSMENT :
▸ Patient is fine according to her lab results, CBC and vital
signs .
▸ stop using Vintoline keep using Kcl
▸ Starting SC insulin beside regular insulin to control
diabetes , try to find the good range for her ( controlled )
▸ Stop using Sodium bicarbonate due to PH reach 7.5 in the
previous day .
FMW

36. INTERVENTION

37. ACCORDING TO THE GUIDELINES THE MANAGEMENT OF DKA IS :
THEY DO IT TO THE PATIENT
THE PATIENT DID NOT NEED IT BUT THEY DO IT
THE PATIENT BG DECREES TO 124 AND BUT HCO3 IS 24 , AG 10 THEY DID NOT STOP IV FLUID OR IV INSULIN
Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis 2013.

38. ▸ The management was on the guideline
▸ But the patient did not need sodium bicarbonate because
her PH never decrees into 6.9 .
▸ Start using SC insulin without decreasing the dose of IV
insulin according to the BG levels .
▸ Patient is newly diagnosed as DM for this she needs to be
educated about her condition .

39. THANK YOU

40. REFERENCES
▸ Cooppan R, et al. Acute complications. In RS Beaser, ed., Joslin's Diabetes
Deskbook: A Guide for Primary Care Providers,2010, 419-443.
▸ Eisenbarth GS, Buse JB Type 1 diabetes mellitus. In S Melmed et al., eds.,
Williams Textbook of Endocrinology, 2011,1436-1461.
▸ Masharani U, German MS. Pancreatic hormones and diabetes mellitus. In DG
Gardner, D Shoback, eds., Greenspan's Basic and Clinical Endocrinology,
2011, 573-655.
▸ Aidar R Gosmanov,1 Elvira O Gosmanova,2 and Erika Dillard-Cannon3 ,
Management of adult diabetic ketoacidosis , 2014, 255–264.
▸ Joint British Diabetes Societies guideline for the management of diabetic
ketoacidosis. Diabet Med. 2011;28(5):508–515