Diabetic Ketoacidosis

Case Report and A practical

approach

Identity of Patient

Name
: Mrs. S
Age
: 65 years old
Gender : Female
Date
: 3 February 2013
No. Med Rec: 70.33.96

History (Alloanamnesis)
Pasien diantar oleh keluarganya ke IGD dalam keadaan tidak sadar.

Menurut keluarga pasien, pasien tidak nafsu makan selama 3 hari

berturut-turut. Pasien hanya makan 2-3 sendok makan per hari.
Sebelum pingsan, pasien terus menerus mengeluh badann terasa
sangat lemas.
Selain itu pasien juga mengeluh terus-menerus merasa haus dan
sering kencing

Riwayat Penyakit Dahulu

Riwayat DM sejak 3 tahun
yang lalu dan mengonsumsi
OHO namun keluarga pasien
lupa namanya dan pasien tidak
teratur minum obat.
Riwayat hipertensi (+) namun
tidak teratur minum obat.
Riwayat Asma Disangkal

Riwayat Penyakit
Keluarga
Riwayat TB disangkal
Riwayat DM disangkal
Riwayat hipertensi
disangkal
Riwayat Asma Disangkal

Riwayat Psikososial
Menurut keluarga pasien, pasien sering makan-makanan manis dan
tidak menjalani diet rendah gula.
Pasien tidak merokok ataupun mengonsumsi alkohol
Pasien pernah mengikuti senam lansia namun tidak rutin

Pemeriksaan Fisik
Keadaan umum:
Sakit berat
Kesadaran:
Coma
Tanda vital
Status Gizi

Suhu
: 37,8oC
Nadi : 147 x/menit
RR : 39 x/menit
TD : 150/95 mmHg

BB : 70 kg
TB : 160 cm
IMT : Obese I

Mulut

Bibir Pucat (-),Bibir Kering (+), Sianosis (-),Gusi berdarah(-) Lidah

kering (+), Lidah kotor (-) Tonsil ( T1 / T1) Faring Hiperemis (-)

Leher

Pembesaran KGB (-), Pembesaran Kelenjar Tiroid (-) JVP 5 +1

cmH2O

Mata

Konjungtiva Anemis (-/-), Sklera Ikterik (-/-), Refleks Cahaya (+/+),

Pupil Isokor

Hidung

Septum Deviasi (-/-),Sekret (-/-),Epistaksis(-/-), mukosa hiperemis

(-/-), konka normal

Telinga

Normotia, Serumen (-/-), hiperemis (-/-).

Hitam, tersebar merata, tidak mudah di cabut

Norrmochepal

Rambut
Kepala

Dada: Normochest
Pulmo:
Inspeksi: Dada simetris (+), Retraksi Dinding Dada (-), Bagian yang
tertinggal saat inspirasi (-)
Palpasi: Vocal fremitus sama kanan dan kiri (+)
Perkusi: Sonor pada kedua lapang paru
Auskultasi: Vesikuler (+), Rhonki (-/-), Wheezing (-/-)
Jantung:
Inspeksi: Ictus Cordis Terlihat (-)
Palpasi: Ictus Cordis Teraba (+) di ICS V linea Midclavicula sinistra
Perkusi: batas kanan jantung relatif di ICS V linea parasternal dextra.
Batas kiri jantung relatif di ICS V linea midclavicula sinistra
Auskultasi: Bunyi Jantung I dan II Murni (+), Murmur (-), Gallop (-)

Abdomen
Inspeksi: Perut datar (+)
Auskultasi: Bising Usus (+) Normal
Palpasi: Abdomen Supel, nyeri tekan epigastrium (-), Hepatomegali(-),
Splenomegali (-)
Perkusi: Timpani pada keempat kuadran Abdomen, shifting dullness (-)

Genitalia
tidak dilakukan pemeriksaan
Regio Flank
Tidak dilakukan pemeriksaan
Ekstremitas Atas :

Akral
: Hangat
CRT
: <2 detik
Edema : -/Ptekie : -/-

Ekstremitas Bawah

Akral
: hangat
CRT
: <2 detik
Edema : -/Ptekie : -/-

Laboratory Findings
Hematologi Rutin
Pemeriksaan

Hasil

Nilai Normal

Hemoglobin

13,2 g/dl

12 16

Leukosit

21,9 x 103/L

4.800 10.000

HCT

37 %

37 47

Trombosit

533 x 103 /L

150.000-450.000

Differential Count
Basofil

0,1 %

0,0 1,0

Eosinofil

0,0 %

1,0 3,0

Neutrofil

87,0 %

37,0 72,0

Lymphocyte

7,3 %

20,0 40, 0

Monocyte

5,6 %

2,0 8,0

Laboratory Findings (Cont..)

Elektrolit
Natrium

133 mmol/L

134-146

Kalium

5,34 mmol/L

3,4-4,5

Chlorida

97 mmol/L

96-108

Kimia Klinik
SGOT

7,6 U/L

0-37

SGPT

10,6 U/L

0-40

Aceton Blood

1,6 mmol/L

Urea

60 mg/dL

Creatinin

1,3 mg/dL

GDS

519,0 mg/dL

Laboratory Findings (Cont..)

Analisa Gas Darah
Temperatur

36,7 oC

pH

7,180

7,400 7,500

PCO2

10,0 mmHg

35 46

HCO3

9,3 mmol/L

22 26

PO2

133,6 mmHg

71 - 104

Base Excess

- 24,8 mmHg

-2 - 3

O2 Saturation

98,1 %

94 - 99

Kriteria KAD

Pada Pasien

Kadar gula darah tinggi (300-600mg/dl)

519 mg/dL

Keton plasma > 1,0 mmol/L

1,6 mmol/L

Osmolaritas plasma meningkat (300-320 mOs/dl)

pH darah < 7,3

7,180

Hiperkalemia

5,34 mmol/L

Nafas Kussmaull

Poliuri

Polidipsi

Fatigue

Kesadaran menurun sampai koma

Anoreksia, mual, muntah, nyeri perut

Kulit kering

Keringat <<<

Diabetic Ketoacidosis
DKA is the end result of the metabolic
abnormalities resulting from a severe

deficiency of insulin or insulin

effectiveness, stress hormone excess.

DKA occurs in 20 40 % of newly onset

diabetes , in children who omit insulin
doses.

DKA: Manifestations
Polyuria , polydepsia , polyphagia

with weight loss.

Nausea , vomiting , abdominal
pain.
Changes in breathing pattern.
Precipitating event : intercurrent
illness, psychosocial stress.

DKA: Diagnosis
Assessment of general status.
Hyperglycemia 300-600 mg/ dl
Acidosis : PH < 7.3
Ketonemia &/ or ketonuria

Classification of DKA
NORMAL

MILD

Moderate

SEVERE

CO2(meq/l
)

20-28

16-20

10-15

<10

PH

7.35

7.257.35

7.15-7.25

<7.15

clinical

No
change

Oriente Kussmul
d alert sleepy
but
fatigued

Kussmaul or
depressed
sleepy, coma

DKA: Treatment
Treatment steps:
Fluid and electrolyte replacement
Correction of hyperglycemia
Correction of complications
Correction of precipitating factors

 K > 5.5 :
20 meq/l
K = 4 5.5 :
40 meq / l
K<4:
60 meq/ l
Replacement should not exceed 0.5
meq/ kg / hr

 1st hour:

DKA protocol

10 20 ml/kg IV bolus 0.9% NaCl or LR

Insulin drip at 0.05 to 0.1 u/kg/hr

Quick volume expansion, may be repeated
NPO
Input & output monitoring, insert catheter if
no output in 4 hrs
Frequent neurological assessment
Mannitol available

 2nd hr till DKA resolves:

0.45 % NaCl + insulin drip + K added.
When blood sugar < 250 mg/dl switch
to 5% glc.
Calculate deficit 85 ml/ kg initial
bolus
Maintenance fluid
Flow sheet
Electrolytes , PH , glucose hourly in
severe DKA, 3-4 hrs in mild to
moderate DKA

 If K < 3 meq /l : 0.5 1 meq/ kg P.O. or

increase IV K to 80 meq/ L.
Transition to oral intake &
subcutaneous insulin , when DKA has
resolved:

pH > 7.3
Stable Na 135- 145 meq/l
No emesis
Co2 > 15 meq/l

 If blood glucose falls below 150 mg/ dl

despite addition of glucose insulin
infusion rate : 0.02-0.05 u/kg/hr
PH & bicarb levels should increase
steadily, persistant acidosis:
Inadequate therapy
Infection
Lactic acidosis

Persistance of ketonuria

Bicarbonate therapy??
Considered if PH< 7.0 , or if there is

inadequate respiratory
compensation( PCO2 > 1.5 x [ HCO3]
+8
Slow infusion over 1 2 hrs of 1-2
meq/kg
No evidence that it improves outcome
Overcorrecting may occur
Hypernatremia, hypokalemia,
hypophosphatemia

Complications: cerebral edema

Cerebral edema is the most frequent

cause of death
Occurs 6 to 18 hrs after initiation of
therapy , often when patient is clinically
iproving
Headache, change in mental status ,
seizuresetc
Continuous drop in Na levels
Almost all patients will have some
degree of subclinical cerebral edema

Complications

Cardiovascular collapse
Hypoglycemia
Hypokalemia
Pancreatitis

 Convert to subcutaneous therapy by

adding up total insulin in 24 hrs &
dividing it into 2 4 doses .
Treatment of the underlying cause
New patients should be followed up .
Children with recurrent DKA , should be
evaluated for therapy failure( family
dysfunction & knowledge deficit)

Differential diagnosis

Gastroenteritis
Severe intraabdominal process
UTI
Pneumonia
Stress hyperglycemia
Hypercalcemia
Salicylate ingestion

Pitfalls in DKA
Plasma glucose is usually high but not

always
High WBC in the absence of infection
Infection may be present in the absence
of fever
Creatinine: some assays cross react
with ketone bodies.
Serum amylase is often raised even in
the absence of pancreatitis

Thank you!