Case 8

An 8-year-old boy was presented to the emergency department with

vomiting and abdominal pain. He had a 2-week history of increased feeling of
thirst, He drinks up to 3 liters per day and has increase appetite, accompanied by
a 3 kg weight loss during last month.
He has had no surgeries, traumas or admissions to the hospital previously.
He had upper respiratory tract infection 1 week ago. He is from the 1st
physiological pregnancy, gestational age 38 weeks. Birth weight 2.9 kg, body
length 51 cm. His immunizations are up to date.
Genetic anamnesis is unremarkable. He attends public school, and does not
know if any of his friends have been ill recently.
Objective Weight 21.5 kg, height 127 cm. BT 37.7°C; RR - 56 per 1
minute. HR - 110 beats per minute, BP 110/65 mmHg; SpO2 98%.
Boy is alert and oriented, normal pupil response. Skin is dry, elasticity of
skin is decreased, 4 second capillary refill time. Chicks are reddish. Oral
mucous membranes is dry, tong is brightly red. There is no significant
lymphadenopathy. Breathing is heavy, quick and loud with fruity odor. There is
no dullness on percussion, vesicular lung sounds on auscultation, no wheezing.
Heart sounds are loud, no murmurs. Abdomen is soft but tender with normal
bowel sounds. Liver 3 cm below costal arch, the spleen was not palpable.
Urination is every hour in large quantity.
Complete blood count
RBC 4.8×1012/L, Hb - 136 g/L, CI - 1,0; WBC – 8.2×109 /L, b – 5 %,
segm – 60 %, e – 2 %, lymph – 30 %, m – 3 %. ESR – 12 mm/hour
Biochemical blood analysis
Parameters Results Units
total protein 72 g/l
glucose 20 mmol/l
total bilirubin 15.6 mmol/l
urea 3.9 mmol/l
creatinine 52 nmol/l
K 4.38 mmol/l
Na 136.1 mmol/l
AlT 38 U/l
AsT 29 U/l
Alkaline phosphatase 260 U/l
Amylase 28 U/l
cholesterol 6.75 mmol/l
triglycerides 0.9 mmol/l
HDL 0.72 mmol/l
LDL 3.03 mmol/l

General urine аnalysis

Parameters Results
Quantity 180 ml
Color Yellow
specific gravity 1040
pH 6.0
Protein absent
Glucose +++
Ketones +++
WBC 1-2 in field of view
 RBC absent
epithelium 2-4 in field of view

8-year-old boy
VBG analysis

o pH: 7.12 (7.35-7.45)

o pO2: 11.5 (10–14)
o pCO2: 3.2 (4.5–6.0)
o HCO3: 9 (22-26)
o BE: -17 (-2 to +2)

Treatment:

Hourly vitals and mental status assessment

COP glucose test every 1-2 hours until blood glucose < 250 mg/dL and stable for at least 3
hours then decrease monitoring to every 3-4 hours

Volume status, Blood gas and BMP every 2-4 hours

Fluid resuscitation

Isotonic Saline solution(0.9% NaCl) 20mL/kg/hr (20x21.5= 430 mL/hr)

Insulin therapy

IV regular insulin bolus 0.1 U/kg once (2.15U) followed by

Continuous Regular insulin IV infusion 0.1 U/kg/hr (2.15 U/hr)

Switch to 5% dextrose in 0.9% NaCl when serum glucose level falls below 200mg/dL
Transition to subcutaneous insulin (preferably basal-bolus insulin regimen once daily)