DIABETIC KETOACIDOSIS
Case history
Clinical assessment Observations: BP 106/67 HR 90 RR 30 Temperature 36.8°C O2 saturation 99% (air) Examination: Slightly drowsy (GCS 13) Dry mucous membranes, slow capillary refill, cool peripheries Ketotic breath Generalised abdominal tenderness
Investigations 3+ ketones, 4+ glucose -ve for blood, nitrites, leukocytes -ve for bHCG 25 mmol/L
Investigations pH 7.24 PaO2 14 kPa; PaCO2 3.5 kPa HCO3- 12 mmol/L WCC 14.5; sodium 130; potassium 5.6 urea 11.4; creatinine ketones 5 mmol/L; glucose 25 mmol/L
Investigations Sinus arrhythmia
Prescribing Elizabeth Austin 23/02/1996 X kg PMH Type I diabetes Asthma (mild) Sunderland Royal Hospital Emergency department Consultant: Dr Watanabe DH NKDA Levemir 16 units ON NovoRapid 6-10 units with meals Ventolin Evohaler 200 micrograms PRN Clenil Modulite 200 micrograms BD Microgynon 30 OD for 21 days, 7 pill-free days
Prescribing 1. Please prescribe appropriate initial fluids 2. Please prescribe the appropriate insulin infusion regimen
Prescribing Treatment is commenced and Liz is being continuously monitored. After five hours: ketones 3 mmol/L glucose 13 mmol/L The equipment is checked and is working correctly. 3. Please continue/modify the treatment as necessary
Prescribing Latest results of monitoring: K+ 3.5 mmol/L capillary glucose 11 mmol/L 4. Please continue/modify the treatment as necessary
Prescribing Liz is reviewed. She still feels nauseated but her blood results are steadily improving, with venous pH 7.28 and ketones 0.7 mmol/L. 4. A colleague suggests converting IV to subcutaneous insulin. Is this treatment appropriate?
Prescribing Her nausea has now resolved and she is requesting food. Blood results: glucose 4.8 mmol/L ketones 0.2 mmol/L pH 7.35 Bicarbonate and potassium normal 5. Please prescribe insulin and her regular medications as appropriate
Prescribing Following the resolution of her DKA, the patient is medically fit for discharge. 6. What further management should be arranged for her?