DIABETIC KETOACIDOSIS IN A 15-YEAR

OLD FEMALE: A CASE PRESENTATION

POST-GRADUATE INTERNS
Dr. Abdul Walli Cana
Dr. Joana Marie Gantuangco
Dr. Susmita Rai
 General Profile
Informant: Patient; Mother
Reliability: 50%; 60%

• K.C., 15 years old, female

• Filipino, Roman Catholic
• From Minglanilla, Cebu
• Admitted for the 5th time on Mar 8, 2019
• Vomiting and chest pain
 Prenatal History
• Mother was 26 years old, G3P2 (2002)
• 1st PNC at 3 months AOG by an OB
• Regular prenatal checkups
• No maternal illnesses
• No maternal comorbidities
• No allergies to food or drugs
• Mother has no vices
 Natal History
• Born full term via NSD at a hospital
• Good cry after birth and pink all over
• Birthweight of 6lbs (2,700g)
• Received BCG and Hep B vaccines, eye
prophylaxis and vitamin K
• Discharged after 2 days
 Post-Natal History
• Exclusively breastfed for 2 months
• Complementary feeding with unrecalled
milk formula
• Newborn screening not done.
• Immunizations from LHC
 HepB3, Hib3, DPT3, PCV3, OPV1,
Measles1
• Developmental milestones
 Currently Grade 7 with average grades
• No known food and drug allergies
 PSYCHOSOCIAL ASSESSMENT
H: lives with her parents and siblings and shares a room with 4
sisters
E: Grade 7 student at UV Minglanilla but stopped schooling
recently

A: Considered to be hard-headed by mother; feels constantly

scrutinized

D: Denies illicit drug use, smoking or drinking alcohol

S: Does not have a boyfriend as claimed

F: Has a good relationship with her parents, sisters and friends.
However, is in frequent conflict with her mother.
I: No image concerns.
R: Usually stays at home and uses the computer. She used to
be part of a dance group and played soccer during Intramurals
in school.
S: Roman Catholic but does not actively participate in Church
activities
T: Had suicidal ideations in the past.
 Past Medical History
• Diagnosed with T1DM last 2005
• Maintenance medications:
 Regular Human Insulin 25U (AM)
 NPH 6U, HRI 6U (PM)
• Taken with poor compliance
• CBG range: 60s-too high
• No other co-morbidities
• Varicella infection on 2018
 Past Medical History
Discharge
Date Hospital Chief Complaint Diagnosis
Condition
2005 CVGH Abrupt weight loss Type 1 DM Improved
Polyuria, Polydipsia

August 26-30 CVGH Tachypnea 1) DKA, Severe Improved

2017 Rashes 2) Type 1 DM
3) Varicella infection
April 24-28, CVGH Tachypnea 1) DKA, Severe Improved
2018 2) Type 1 DM
July 24-27, CVGH Tachypnea 1) DKA, Severe Improved
2018 2) Type 1 DM
 OB History
• Menarche at 13 years old
• Regular monthly cycles, lasts 3-7 days,
consuming ~3 moderately soaked pads/
day, mild dysmenorrhea
• No coitarche
 Personal and Social History
• Eats 3 meals with snacks
• Fond of eating junk food, cookies, candies
• Drinks >3L of water/day, urinates 3-5x/day
• No vices
• Lives with parents and siblings
• Grade 7 student at UV Minglanilla
• Used to be active in dancing
 Family History
• Hypertension on both sides
• Paternal side: T2DM, asthma
• No known relatives with T1DM
 History of Present Illness
• Vomiting x 1 episode
• Chest pain, dizziness
3hrs
• CBG 481mg/dl4U Regular Insulin given SC
• 2 more episodes of vomiting
2hrs • Epigastric pain, body malaise
• CBG 485mg/dl
• No fever, dysuria, cough, trauma
• No change in sensorium
• Persistence of symptoms prompted patient
to be brought at CVGH-ER
 Physical Examination
Drowsy, in respiratory distress
BP: 100/60 mmHg (left arm, lying)
RR: 32 cpm HR: 117 bpm
T: 36.5C sO2: 98%
Ht: 142 cm (Z score: < -3)
Wt: 43.5 kg (Z score: -2 to -1)
BMI: 21.57 kg/m2 (Z score: 0 to 1)
Cool to touch, good turgor and mobility, no lesions
 Physical Examination
White sclerae, pink palpebral conjunctivae, pink
dry lips, no alar flaring
Supple, no lymphadenopathies

Equal chest expansion, no retractions, Kussmaul’s

respiration, resonant, clear breath sounds
PMI palpable at 5th ICS, distinct S1 and S2,
no murmurs, tachycardic, regular rate and rhythm
 Physical Examination

Flabby, tympanitic, normoactive bowel sounds, soft

Direct tenderness at epigastrium upon light palpation
Negative Kidney Punch Sign

Cool, clammy hands and feet, CRT <2 seconds,

strong pulses
Drowsy, oriented to person, place and time,GCS15
Cranial nerves: I- not assessed
II, III- (+) EBRTL
III, IV, VI - full range of extra ocular muscles
V- strong muscles of mastication
VII- good facial expressions
VIII- able to hear spoken voice at 2 ft
IX, X- (+) gag reflex
XI- able to turn head and shrug shoulders against resistance
Cerebellar: Well-coordinated movements
Sensory: Intact light touch and pain sensation on all extremities
Motor: 5/5 on all extremities
Reflexes: +2 biceps, +2 patellar, (-) Babinski
Clinical Formulation
Diabetic Ketoacidosis
 15 years old, female,
Diagnosed case of Type I Diabetes Mellitus
With acute onset vomiting
Nelsons Textbook of Pediatrics 20th Edition
 Acute onset
vomiting

Infant Child Adolescent

Gastroenteritis, Gastroenteritis, Gastroenteritis, Peptic Ulcer,

GERD, Brain Tumor,
Systemic Infection, Food poisoning, Systemic Infection, Increased Intracranial
Antibiotic Associated Systemic Infection, Toxic Ingestion, pressure,
Gastritis, Middle Ear Disease,
Overfeeding, Antibiotic associated, Sinusitis, Chemotherapy,
systemic infection, Gastritis, Inflammatory bowel Cyclic vomiting (migra
disease, ine),
Pertussis syndrome, Toxic Ingestion, Appendicitis, Biliary colic,
Otitis media, Pertussis syndrome, Migraine, Renal colic,
Pregnancy,
Adrogenital Syndrome, Reflux (GERD), Medication,
Diabetic Ketoacidosis
Inborn error of metabolism Sinusitis, Ipecac abuse,
Otitis media, Bulimia,
Concussion
Anatomic Obstruction Reye Syndrome,
Hepatits,
 Gastrointestinal Infectious Endocrine
Gastroenteritis, Systemic Infection,
Gastroenteritis, Peptic Ulcer, Diabetic Ketoacidosis
GERD, Brain Tumor,
Gastritis, Sinusitis,
Systemic Infection, Increased Intracranial
GERD, Hepatitis.pressure,
Toxic Ingestion, Trauma
Inflammatory bowel disease, Gastritis, Middle Ear Disease,
Concussion
Sinusitis, Chemotherapy,
Appendicitis, Inflammatory Oncology
bowel Cyclic vomiting (migra
Peptic Ulcer, disease, ine),
Neurology
Pancreatitis Brain Tumor,
Appendicitis, Biliary colic,
Migraine, Renal colic, Migraine
Chemotherapy
Pregnancy, Diabetic Ketoacidosis
Medication,
Ipecac abuse, Others
Bulimia,
Concussion Pregnancy,
Reye Syndrome, Medication,
Hepatits,
Ipecac abuse,
Bulimia
 Diabetic Ketoacidosis

Type 1 Diabetes Mellitus since 2005 Drowsy

Two previous onsets of Diabetes
Ketoacidosis(April 2018, August 2018)
Presented with acute onset vomiting
and nausea
Abdominal pain
Tachycardic, tachypneic
Dry lips, cool clammy hands
Fruity odor breath
Kussmaul respiration
Course in the Wards
 Hospital Day 0 (1st 6 hours)
600
CBG (mg/dL)
500 512 Urine Output (cc)
468
441
400
352
300
223 231 226
200

100

0
5:45 AM 7:30 AM 8:30 AM 9:30 AM 10:30 AM 11:00 AM 12:00

• NPO, ABG
PICU set-up PLR + 20 45 mEqs ABG PLR+20mEqs
• PNSS
pH 900cc
6.9 over mEqs KCl •NaHCOpH 3 +6.9 KCl  D5LR +
• 1hr (20cc/kg)
pCO2 11.6 at 130cc/h •equal
pCO2amt 11.6
of 20mEqs KCl at
• 50HRI+50cc
pO2 136 NSS by infusion •diluent
pO2 to run
157in 130cc/h
• 40cc/hr6(AD: 0.1)
HCO3
at pump •1hr
HCO3 5.9
• Cardiac monitor
TCO2 2.7 • TCO2 2.6
• ABG,
ABE HbA1 C, UA
-29.4 • ABE -29.4
• Na, K, Creatinine
sO2 97.2 • sO2 97.3
Laboratory Tests
Urinalysis
Gross Straw, slightly cloudy
pH 5.0 Clinical Chemistry
Sp. Gr. 1.025 (H) HbA1C >14.5%
Glucose ++++ Crea 1.0 (CrCl 58.6)
Ketone ++++ Sodium 141mg/dl (147.8)
Blood + Potassium 5.6
Proteins +++ Chloride 115 (H)
RBC/HPF 0-2
WBC/HPF 1-3
Cast FGC 0-1/HPF
SEC 2/HPF
 Hospital Day 0 (after 1st 6 hours) HRI
300 CBG (mg/dL)
Urine Output (cc)
250
231 222
207 205 213 207
200 197
167
150

100 97 96
68
50

0
1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 8:00 PM 10:00 PM 2:00 AM 4:00 AM 6:00 AM

ABG VBG • Liquid diet • Full VBG

diet
pH 6.9 • pH 7.1 • ↓ CBG •↓ pHInsulin 7.2
from
pCO2 11.6 • pCO2 25.4 monitoring q2h • pCO2
40 36.0
to 20cc/h
pO2 157 • pO2 36.5 • pO20.05ukh)
(AD: 45.6
HCO3 5.9 • HCO3 10.2 •↓ IV rate 17.3
HCO3 from
TCO2 2.6 • TCO2 7.7 •130
TCO2 15.1
to 100cc/h
ABE -29.4 • ABE -20.1 • 10U
ABE HRI-8.7acbf
sO2 97.3 • sO2 69.6 • CBG
sO2 ac lunch
86.7
 Course in the Wards
HD 1 HD 2 HD 3

S: No recurrence of S: No recurrence of S: No recurrence of

vomiting, chest pain vomiting, chest pain; good vomiting, chest pain; good
O: HR: 98-157 bpm appetite appetite
RR: 21-35 cpm O: HR: 76-96 bpm O: HR: 64-95 bpm
(-)Kussmaul RR: 20-22 cpm RR: 20-21 cpm
Skin is warm UO: 1.91mkh UO: 2.94mkh
GCS 15, UO 1.38mkh CBG 179-355 CBG 191-250
CBG 197-252m A: Stable, clinically A: Stable, resolving
A: DKA, improving improving P: Mixtard30 25U SC ACBF
P: O2 supp at 1lpm prn P: Rpt Na (140), K (3.9) Remove trifuse
DC cardiac monitor To consume IVF+KCl NPH 8U + HRI 7U AC sup
Insulin inf at 20cc/hr NPH 8U + HRI 10U SC For diabetic diet 1900kcal
PLR+20mEq KCl 100cc/h (50% CHO, 30% fat, 20%
HRI 10U SC CHON)
 Course in the Wards (HD1-3)
600 CBG (mg/dL)
Urine Output (cc)
500

400
355 368
300
267 276
252 248 250
224 226 228 219.5 220
200 197 191
179

100
69
0
6:00 10:00 2:00 6:00 10:00 6:00 10:00 2:00 6:00 10:00 6:00 10:00 2:00 6:00 10:00 6:00
AM AM PM PM PM AM AM PM PM PM AM AM PM PM PM AM

• D5LR  PLR+
•Insulin • Rpt Na 140
8U NPH
20mEqs KCl at
infusion • Rpt K 3.4
7-10U HRI
discont’d
100cc/h • TC IVF+KCl
• ↓ IV from 100 to  PLR at 10UHRI

60-65cc/h (MF) 65cc/h (MF) 25U Mixtard

Hospital Day 4
• Discharged with take home medications:
• 25U Mixtard30 (30mins-1hr) before breakfast
• 7U NPH + 8U HRI (30mins-1hr) before dinner
• For diabetic diet 1900kcal divided into 3 meals
(50% CHO, 30% fats, 20% CHON)
• Self-monitoring of CBG 30mins prior to meals and at
bedtime
• Follow up with AP after 1 week
Case Discussion
Diabetic Ketoacidosis
Epidemiology
Initial Presentation Established DM

1510%
%-70% 90% 6%-830%
% per yr
• Younger children (<2 yo) • Previous episodes of DKA
• Ethnic minority groups • Vomiting with dehydration
• Delayed dx of DM Children and
Across whole • Peripubertal, pubertal girls
DKA
• lifeinspan
Living countries with • History of psychiatric
adolescents
low prevalence of T1DM disorders
• Omission of insulin

ISPAD Clinical Practice Consensus Guidelines 2018

Diagnostic Criteria for DM

Nelsons Textbook of Pediatrics 20th Edition

Pathogenesis of Type 1 Diabetes Mellitus

HLA
DR3/4-
DQ2/8
Pathogenesis of Type 1 Diabetes Mellitus
 Insulin

Nausea

Hypokalemia
Kussmaul

Hyperkalemia ISPAD Clinical Practice Consensus Guidelines 2018

 Diagnostic Criteria for DKA
CRITERIA PATIENT
Blood glucose >11 mmol/L (200 mg/dL) 441 mg/dL

Venous pH <7.3 6.9

Serum HCO3 <15 mmol/L 6.0 mmol/L

Ketonuria ≥2+ 4+
(or ketonemia) (BOHB ≥3 mmol/L)

ISPAD Clinical Practice Consensus Guidelines 2018

 Severity of DKA
CRITERIA
Venous pH TCO2 Clinical
Mild 7.25-7.35 16-20 Alert but fatigued
Moderate 7.15-7.25 10-15 Kussmaul respiration,
sleepy but arousable

Severe <7.15 <10 Depressed respiration Corrected Na >150

or sensorium mEq/L
6.9 2.7 147.8
Nelsons Textbook of Pediatrics 20th Edition
ISPAD Clinical Practice Consensus
Guidelines 2018
DKA Treatment Protocol

Nelsons Textbook of Pediatrics 20th Edition

ISPAD Clinical Practice Consensus
Guidelines 2018
ISPAD Clinical Practice Consensus Guidelines 2018
Insulin Therapy
• DCCT: intensive insulin therapy + multidisciplinary approach  lower rate
of long-term complications

Nelsons Textbook of Pediatrics 20th Edition

Insulin Therapy
Complications

DKA 0.27 Death

30%
%

DKA Deaths 60 to
caused by Cerebral Edema 90%
DM-Related Complications
Other Complications

• Hypoglycemia
• Lipohypertrophy and lipoatrophy
• Necrobiosis lipoidica (NL) diabeticorum
• Vitiligo
• Insulin edema
Patient Education

• Nutritional management
• Self-monitoring of blood glucose
 80mg/dl-140mg/dl
• Exercise
• Behavioral/Psychological Aspects
• Major depressive disorder
• Eating disorders