SUGAR RUSH:

Diabetic KetoAcidosis
Earl Karyl F. Galvez
PCGH Level 1 Resident
OBJECTIVES
Clinical Case
General Data
●P.E,
●22 year old
●Female
●Single
●Filipino
●Pasig City
●Pasig City General Hospital June 5, 2023.
Chief Complaint

Epigastric pain
History of Present Illness
Few
1 day hours

Type 1 DM Epigastric pain

since 9 yrs old 8/10 Consult

Insulin 70/30 Non-Radiating

28-0-18
Vomiting 10x
Past Medical History
Childhood Illness Previous Allergies and Medications
Hospitalizations, Blood Transfusion
Unremarkable
Accidents,
Surgeries
Insulin 70/30
1. Type 1 DM (9yrs old) at
None
NCH
28-0-18
2. DKA(11 yrs old) at PCCH
Family History
● Both parents
● DM history
● No other heredofamilial diseases
Personal and Social History
➔ Highschool student
➔ On keto-diet
➔ Non smoker
➔ Non-alcoholic beverage drinker

➔ OB GYN History
➔ M: 13 yrs old
➔ I: Regular
➔ D: 1-3 pads per day
➔ A: fully soaked
➔ S: No dysmenorrhoea
.
Review of Systems
General (-) weight loss (-) fever (-) chills (-) loss of appetite (-) malaise

(+) Dizziness (-) eye pain (-) blurring of vision (-) diplopia
HEENT
(-) ear discharge (-) tinnitus (-)epistaxis (-) hoarseness (-) lacrimation

(-) hemoptysis (-) back pain (-) orthopnea (-) difficulty of breathing
Respiratory
(-) cough (-) sputum production

(-) edema (-) cyanosis (-) syncope (-) paroxysmal nocturnal dyspnea
Cardiovascular (-) palpitation (-) chest pain,

(-) dysphagia (-) diarrhea (-) hematochezia (-) melena (-) dysphagia
Gastrointestinal
(-) hematemesis (-) abdominal enlargement (-) loose stool
(-) abdominal pain
Review of Systems
Genitourinary (-) incontinence (-) discharge

(-) edema (-) swelling of joints (-) stiffness (-) numbness

Musculoskeletal (-) muscle pain (-) muscle weakness (-) muscular atrophy

(-) loss of consciousness (-) paralysis (-) numbness (-) paresthesia

Neuropsychiatric (-) speech disorder (-) tremors (-) depression

Endocrine (-) intolerance to heat and cold (-) abnormal growth

Hematopoietic (-) bleeding (-) easy bruising (-) pallor

 Physical Examination

Findings
General Survey Patient is awake, conscious, coherent and cooperative. The patient is properly groomed, and with no visible gross
deformities. No visible involuntary movements

Vital Signs and BP=100/70 Weight = 50 kg

Anthropometric PR=135 Height = 5ff
Measurement RR=22 Waist: 34 inches (86.36 cm)
Temp=38 Right Axilla BMI 23 (normal)
O2sat = 98% room air

HEENT Anicteric Sclerae, (-) Tonsillopharyngeal Congestion, Dry lips, Dry buccal mucosa, Pale palpebral
conjunctivae
(-) Naso-Aural Discharge, (-) Cervical Lymphadenopathy

Chest & Lungs (-) Retractions, (-) Chest Lag, Clear Breath Sounds

Cardiovascular Adynamic precordium, No Heaves, No Thrills, Normal Rate and Regular rhythm,

Abdomen Globular, No striae, No spider angioma, Normoactive Bowel Sounds, Non tender, (-) Shifting dullness test, (-)
Fluid wave test
 Physical Examination

Findings
Genitourinary N/A

Extremities No Cyanosis, No Bony deformities, No redness, bulging and depression. No Muscular atrophy.
Capillary Refill Time <2s
 Physical Examination

Neurologic Findings
Cerebrum Patient is conscious, coherent, alert, cooperative with intact remote, recent and immediate memory. Oriented to
time, person and place.

Cranial Nerves I Not assessed

II, III Pupils are 2mm wide, equally reactive to direct and consensual lighting

III, IV, VI Intact and full extraocular movements. No nystagmus

V Intact V1-V3. Can clench both temporalis and masseter muscles. Intact Corneal reflex
VII Able to demonstrate different facial expressions such as by raising eyebrows, open and closing eyes,
frown, smile, wrinkle forehead, pout, purse lip, and puffing of cheeks.
VIII Able to hear and relay whispered words on both ears.
IX, X Uvula in midline. Palate symmetrically rising. Intact Gag reflex
XI Able to shrug shoulders and rotate the head against resistance.
XII Tongue at midline moves with ease upon retraction and protrusion, can move from side to side

Cerebellum Able to do finger to nose test. Able to do alternate and supination movement of the hand to thigh.

Sensory Function 100% on both left and right upper extremities,

Able to distinguish sharp sensation and dull sensation on bilateral lower extremities
 Physical Examination

Neurologic Findings
Motor Function Muscle strength is 5/5 on lower extremities and 5/5 on upper extremities

Reflexes Biceps = +2
Triceps = +2
Babinski sign: Negative

Meningeal Negative for nuchal rigidity, Negative for Brudzinski sign and Negative for Kernig's sign.

100% 100% 5/5 5/5 ++ ++

100% 100% 5/5 5/5 ++ ++

Sensory Motor DTR

 Salient Features
Epigastric pain Both parents: Diabetic
Vomiting
Dizziness
Tachycardic
Tachypneic
Dry lips
Pale conjuctiva

Keto-diet
Type 1 DM since 9 yrs old
History of Hospitalization
Primary Working Impression

Diabetic Keto-Acidosis
Differential Diagnosis
Reason for ruling in Reason for ruling out

HHS Epigastric pain

vomiting,
diabetic,
signs of
dehydration
Differential Diagnosis
Reason for ruling in Reason for ruling out

(-) Jaundice
(-) bowel movement that
Pancreatitis Fever
appear oily and are extra
Epigastric pain,
pungent
vomiting
(-) upper abdominal pain
that radiating to the back
Differential Diagnosis
Reason for ruling in Reason for ruling out

Acute Epigastric pain, (-) hx of ingestion of

Gastro- vomiting, particular food, exposure
enteritis signs of dehydration to contaminated water,
travel
ER LEVEL
21
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(+) Epigastric pain AS Paled Conjuctiva CBC pc, Serum electrolytes
(+) vomiting , 10x (previously SCE (-) Crackles, (-) rales BUN, CREA, ASL, ALT
ingested food) Globular abdomen, Epigastric CBG---358mg/DL
(+)Palpitation tenderness, (-) no UA
(+) Fever direct/indirect tenderness nor CXR
rovsing sign noted ECG 12 lead
(-) DOB GNE (-) cyanosis and edema FBS, lipid profile
(-) chest pain Urine ketones
Vital signs ABG
Bp 100/70
CR 135
RR 22
T 38.6
O2 sat 99 room air

22
CBC 6/5/23 Chemistry 6/5/23 U/A
HGB 137
BUN 7.17 Color yellow
HCT 0.42
PLT 381 CREA 88 PH TURBID
WBC 15.4(H) Na 139 SG 1.025
N 0.81(H)
K 4.8
L 0.15 PUS 20-30
MG 0.75
RBC 3-5
PH 7.118 CA 2.37
Ketone +3
PCo2 18.9 Cl 102
Hco3 8.2 Albumin +1
ASL 19
BE -21.5
Sugar Negative
02 98.8 ALT 16

23
Chest X-RAY
- Clear lungs

24
ECG

25
 From: Hyperglycemic Crises in Diabetes

Diabetes Care. 2004;27(suppl_1):s94-s102. doi:10.2337/diacare.27.2007.S94

Figure Legend:
DKA/HHS flowsheet for the documentation of clinical parameters, fluid and electrolytes, laboratory values, insulin therapy, and urinary output. From Kitabchi et al. (14).

Date of Download: 7/12/2023 Copyright © 2023 American Diabetes Association. All rights reserved.
 27

Presentation Title 9/4/20XX

IVF: 1L/HR
Additional of 2L 6hrs
 28

Presentation Title 9/4/20XX

IVF: 150cc/hr
Insulin 70/30
36-0-20
PLAN

IVF: PNSS 1L x 150cc/hr

DIET: DM

1.Paracetamol 600mg tiv Q4 for fever > 38

2.Omeprazole 40mg tiv stat then OD
3.Metoclopromide 10mg tIV PRN for Vomiting
4. HNBB 1 amp TIV PRN for abdominal pain
5. Insulin 70/30 36-0-20
6.Ceftriaxone 2g TIV OD

29
Discussion

30
 DIABETIC
DIABETES
KETOACIDOSIS
• It is a chronic, metabolic disease characterized by elevated
•Life-threatening.
levels of blood
•Most
• Thecommon among is
most common people
type 2with type 1usually
diabetes, diabetes.
in adults, which
occurs when the body becomes resistant to insulin or doesn't
•People
makewith type insulin.
enough 2 diabetes

•Ketones.

https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html
 • Hospital admissions were associated with a 5.2%, 13.5%,
and 23.4%

• Risk of death during a median follow-up period of 4.1, 3.7,

and 2.4 years respectively

https://www.healio.com/news/endocrinology/20160712/recurrent-dka-increases-mortality-risk-in-atrisk-patients-with-
diabetes
 33

Pathophysiology
• Insulin deficiency has three main effects:
1. Loss of insulin-dependent glucose transport into peripheral tissues
2. Increased gluconeogenesis in the liver
3. Increased breakdown of fat, protein, and glycogen

Thus, insulin deficiency results in hyperglycemia) and acidosis

Common Cause: New onset, intercurrent illness, insulin pump

malfunction, or purposeful insulin omission

https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html
 From: Hyperglycemic Crises in Adult Patients With DiabetesA consensus statement from the
American Diabetes Association
Diabetes Care. 2006;29(12):2739-2748. doi:10.2337/dc06-9916

FBS: 10.06(H)
Cho: 5.5(H)
TG: 1.05
HDL: 3.19 (H)
LDL 1.8

HBA1C 12.5

Figure Legend:
Pathogenesis of DKA and HHS, stress, infection, and/or insufficient insulin. ++Accelerated pathway (ref. 10).

Date of Download: 7/9/2023 Copyright © 2023 American Diabetes Association. All rights reserved.
 35

Clinical Signs
• Dehydration (polyuria)
• Tachycardia
• Tachypnea
• Deep, sighing(Kussmaul)
respiration
• Acetone breath
• Nausea, vomiting
• Abdominal pain that may mimic an
acute abdominal condition
• Confusion, drowsiness, progressive
loss of consciousness.

https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html
 Precipitating Factors of DKA
• Medical condition • Diet: keto Diet
▫ Infection
▫ myocardial infarction • Medication
▫ cerebrovascular accidents ▫ Corticosteroids
▫ pulmonary embolism ▫ thiazide diuretics
▫ Pancreatitis ▫ sympathomimetic agents (e.g., dobutamine
▫ alcohol and illicit drug use and terbutaline)
▫ second generation antipsychotic agents
• ▫ Sodium-glucose cotransporter 2 (SGLT-2)
Very young children inhibitors (canagliflozin, dapagliflozin, and
• Lower social economic Background empagliflozin)
• Prior poor compliance
• Concomitant psychiatric disease
• Adolescent girls

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 38

Diagnosis/Biochemical
• Diabetes 🡪 Hyperglycemia (BG>11mmol/L or 200 mg/dL)

• Keto 🡪 Ketones in the urine or blood (Ketonuria orGlucose: 358

Ketonemia) 🡪
βhydroxybutyrate (BOHB); a level ≥3mmol/L is indicative
Ketones; +of3 DKA

• Acidosis 🡪 Venous pH <7.3 or bicarbonate <15 mmol/L

HCo3: 9.7
▫ Mild: venous pH<7.3 or bicarbonate <15mmol/L
PH: 7.1
▫ Moderate: pH<7.2, bicarbonate <10mmol/L
▫ Severe: pH<7.1, bicarbonate <5mmol/L.

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 Glucose: 358

Ketones; + 3

HCo3: 9.7

PH: 7.1

Table 344-4; Harrison’s Principles of Internal Medicine

Diabetes Care. 2006;29(12):2739-2748. doi:10.2337/dc06-9916
 Management:
DKA GOAL Strategy
➔ Fluid Resuscitation
➔ Electrolyte Imbalance
➔ Hyperglycemia
➔ Identification and prompt treatment of co-morbid precipitating
causes

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 42

Complication of DKA
Correction of Dehydration, electrolyte deficits, hyperglycemia,
and acidosis.

A. Cardiovascular collapse
▫ From dehydration
▫ Treatment involves intravascular fluid expansion with
ISOTONIC fluids

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 43

Complication of DKA
B. Overwhelming acidosis
▫ From ketoacid production and lactic acid accumulation
▫ Volume expansion and tissue reperfusion to correct lactic acidosis
▫ Prompt initiation of insulin to stop fatty acid oxidation and
ketone production
▫ sodium bicarbonate if arterial pH < 6.9 and/or evidence of
myocardial depression/collapse

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 44

Complication of DKA
• C. Hypokalemia
▫ Insulin therapy is associated with rapid intracellular movement
of potassium
▫ Adequate potassium replacement in rehydration fluids and
frequent monitoring with blood tests and EKG’s

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 From: Hyperglycemic Crises in Adult Patients With DiabetesA consensus statement from the American Diabetes
Association
Diabetes Care. 2006;29(12):2739-2748. doi:10.2337/dc06-9916

Date of Download: 7/9/2023 Copyright © 2023 American Diabetes Association. All rights reserved.
 • Fluid Resuscitation
WD: Current NA + 145 -1 x 0.6
x wt
Total body water deficit of 6 L in DKA
and 9 L in HHS NA:139
139+ 145 = 284
284-1 = 283
• Initial fluid of choice
283x.6 =is isotonic saline
169.8
169.8x50kbw
at the rate of 15–20 = 8,490
per hour or 1–
1.5 L during the first hour.

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 • Address Hyperglycemia
• Insulin infusions should be started at 1-2

units/hour
• Consider lower infusion rate in ESRD and/or

severe labile glucose

• DO NOT lower blood glucose too rapidly! Can

result in cerebral edema, hypoglycemia, and

hypokalemia

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 • When plasma glucose reaches 200-250 mg/dL in DKA or 300 in HHS,

• The rate of insulin infusion should be adjusted to maintain blood glucose

between 150-200 mg/dL in DKA until it is resolved,

• 250-300 mg/dL in HHS until mental obtundation and hyperosmolar

state are corrected

Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In: Feingold KR, Anawalt B,
Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279052/
 Transitioning from Insulin Drip to SQ Insulin
• Do not discontinue in less than 12 hours
• Should not be done until:
• glucose < 200 mg/dL, serum bicarbonate > 15 mEq/L, anion gap < 12 mEq/L and a
venous pH of > 7.3
• Overlap with the long acting insulin by 2 hours
• Patients with known diabetes can be restarted at their pre-DKA insulin
regimen
• Dextrose containing fluids should be discontinued at this time as well

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 52

What about K (Potassium)?

• Potassium deplete
• Therapy (insulin and
correcting acidosis) cause K
to shift back into cells
• Check EKG/monitor
• Replete K if renal function
okay

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 Correct Electrolyte Imbalances

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 Correct Electrolyte Imbalances

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
 55

Presentation Title 9/4/20XX

What about Bicarb?

• No recommended for routine care
• Can lead to paradoxical worsening
• And associated with higher risk of cerebral edema
• Consider use of sodium bicarbonate in patients with arterial pH <
6.9 and/or evidence of myocardial depression/collapse

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
Bicarbonate Therapy
• If pH >7.0, insulin therapy inhibits lipolysis and also corrects
ketoacidosis without use of bicarbonate.

• If pH between 6.9 and 7.0, it may be beneficial to give 50 mmol of

bicarbonate in 200 ml of sterile water with 10 mmol KCL over two hours
to maintain the pH at > 7.0

Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In:
Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK279052/
 Resolution of DKA
➔ Improvement in mental status

➔ Vital signs return to baseline (BP, HR, RR)

➔ Patient can tolerate oral intake

➔ Volume status is corrected

➔ pH >7.3

➔ Glucose <250 mg/dL

➔ Bicarbonate >17 mEq/L

➔ Anion Gap <15

https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crises-in-Adult-Patients-With
Ward Level

58
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(-) Epigastric pain AS Pale Palpebral Conjunctiva Repeat Serum k, NA, Mg
(-) vomiting SCE (-) Crackles, (-) rales ASL, ALT
(-) DOB Globular abdomen, no Epigastric Repeat ABG
(-) chest pain tenderness, (-) no direct/indirect Urine GSCS
(-) Fever tenderness nor rovsing sign noted CBG TID Premeals
GNE (-) cyanosis and edema

Vital signs
Bp 100/70
CR 78
RR 220
T 36.6
O2 sat 97 room air

59
Problems:
1.DKA-resolving
2.Complicated UTI

60
PLAN

Diet: DM with SAP

IVF: PNSS 1L x 60cc/hr
CBG TID pre Meals
VS q 4
I&O Q shift

Medication:
1. Ceftriaxone 2gms tiv OD
2. Paracetamol 300mg tiv PRN for fever
3. Omeprazole 40mg cap OD
4. Insulin 70/30 (36-0-20)
5. HR 4 units SQ Pre lunch; if CBG > 180 mg DL

For referral to Dietary for diet counselling

For referral to Ophtha service
61
CBG 6/8/23 6/9/23 6/10/23 6/11/23 6/12/23 6/13/23

7am 245 68 80 250 221 154

12nn 143 296 202 152 231 84

5pm -- 144 -- -- -- --

7pm 240 173 96 160 120 116

Insulin 36-0-20 32-0-16 20-0-12 20-0-16 20-0-16 20-0-16

70/30

HR 6 units 6 units 6 units 6 units 6 units

preLunch

ACTUAL 36-6-20 Hold-8-20 Hold-8- 20-6-16 20-8-16 20-0-16

GIVEN Hold
62
 6/8/23 6/11/23

CBC with PC 6/9/23 6/11/23

BUN

Crea
Hgb 123 119
Na 139 145
Hct 0.37 0.36
K 4.8 4.6
Plt 298 250
Cl 102
WBC 4.3 5.9 Ca 2.37
N 0.43 0.45 Mg 0.66

L 0.47 0.40 AST 11

M 0.07 0.07 ALT 23

 6/7/23 6/9/23
Color Y LY
Transparency T ST
pH 6.0 6.5
Sp gravity 1.025 1.020
Albumin +1 negative
Ketone +2 +2
Pus cells 20-30 0-1
RBC 3-5 5-7
Squamous cells many few
 65

Presentation Title 9/4/20XX

• Urine Culture
▫ No growth after 48 hours of incubation
• Hba1c
▫ 12.5
DISCHARGE PLANNING

Home Medication:
1. Cefixime 200mg tablet bid x 7 days
2. Omeprazole 40mg cap OD x 5 days
3. Insulin 70/30 (20-0-16)
4. HR 6 units SQ Pre lunch; add 2 units if CBG > 180 mg/dl,
5. Hold insulin HR if CBG less than 90mg/dl
6. MN snack Nutren Diabpro 3 scoops in 150ml of water

Follow up at IM OPD after 2 weeks

Continue CBG monitoring

66
MGH

67
 Final Diagnosis
Diabetic KetoAcidosis-
Resolved
Complicated UTI-Resolved
Type 1 DM

68
 22/Female + Type I DM
Epigastric tenderness
Vomiting On keto diet
Dizzines Both parents: Diabetic
History of DM since 9 yrs
tachycardic old
Tachypneic History of Hospitalization
Dry lips
Pale conjuctiva

Gluconeogenesis Ketogenesis Free fatty Acids

Glucose Utilization(muscle Glycogenolysis

Hyperglycemia Metabolic Acidosis

69
Hyperglycemia Ketogenesis

Glucosuria
Ketoacidosis

Dehydration Ketonuria

Admission
70
Take Home Message
• DKA is a life-threatening complication of diabetes mellitus
• Fluid therapy and insulin remains the key factors for
managing DKA and frequent monitoring is essential
• DKA can be prevented through patient education and
adherence to medication
References:
https://diabetesjournals.org/care/article/29/12/2739/26342/Hyperglycemic-Crise
1 s-in-Adult-Patients-With

2
Hyperglycemic Crises in Adult Patients With Diabetes A consensus statement from th
e American Diabetes

https://diabetesjournals.org/spectrum/article/18/1/20/1869/Hyperglycemia-in-the-
Hospital
3.

4.
https://diabetesjournals.org/care/article/27/2/553/28286/Management-of-Diabetes-a
nd- 72