Case

PMH

1.  Type 1 diabetes mellitus:

-- Diagnosed at 12 years of age with first episode of diabetic ketoacidosis.

-- Followed by Dr. Julia Creider in the community.

-- Last HbA1c 11.1% in August 2018.

-- Recent admission to Medicine at University Hospital for diabetic ketoacidosis in July 2018.

2.  Seasonal asthma

MEDS

1.  Lantus 34 units subcutaneous at bedtime.

2.  NovoRapid 10 to 12 units subcutaneous t.i.d. with meals.

CC: N/V Abdo Pain

What is DKA?

DKA

Complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria

Pathophysiology?

DKA Pathophysiology

• Insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes
• Extracellular fluid volume (ECFV) depletion
• Potassium is shifted out of cells
• Ketoacidosis occurs as a result of elevated glucagon levels and insulin deficiency

Diagnose DKA?

DKA Triad:

Hyperglycemia, Anion-gap Metabolic Acidosis, Ketonemia

Differential DDx

Anion Gap Metabolic Acidosis

GOLDMARK

Case

 History?

Triggers

• Infection
• Ischemia
• Ignorance (not using meds)
• Intoxication
• Intrauterine pregnancy
• Idiopathic (new diagnosis)

DKA TIME!!!

Glucose 21.9

Glucose 19.9-->12.1

THERE WAS NO POTASSIUM IN THE BAG!!!

AG 20-->16

pH 7.27-->7.32

Glucose 8.5-6.4

Glucose 6.4-->

5.8-->6.1-->4.6!!!

Glucose 4.6-->10.8

-->17.3

AG 15-->17

Glucose 17.3-->13.4

AG 17-->14

Glucose 13.4-->10.9

AG 14-->12, pH 7.41

WE DID IT

Wait now what?

MEDS

1.  Lantus 34 units subcutaneous at bedtime.

2.  NovoRapid 10 to 12 units subcutaneous t.i.d. with meals.