Diabetic Ketoacidosis (DKA)

Preceptor :Deddy Satriya Putra, S.Ked,.dr.,Sp.A (K).

Presented by:Rahmi Diffilianti

Introduction

Diabetic ketoacidosis is a major cause of morbidity and mortality in children with type 1 diabetes mellitus

Mortality is mainly associated with cerebral edema that occurs around 57 % - 87 % of all deaths from KAD

DKA prevalence in the United States is estimated at 4.6 - 8 per 1,000 diabetics with mortality of about 2-5 % .

in Indonesia incidence of deaths from 0.15 - 0.3 %

Definition

results from absolute or relative deficiency of circulating insulin and the combined effects of increased levels of the counterregulatory hormones: catecholamines, glucagon, cortisol and growth hormone

Frequency of DKA

There is wide geographic variation in the frequency of DKA at onset of diabetes; rates inversely correlate with the regional incidence of T1DM.

Frequencies range from approximately 15% to 70% in Europe and North America (A) (23–27). DKA at diagnosis is more common in younger children

Clinical manifestations

• Dehydration • Rapid, deep, sighing (Kussmaul

respiration) • Nausea, vomiting, and abdominal

pain mimicking an acute abdomen • Progressive obtundation and loss of

consciousness • Increased leukocyte count with left

shift • Non-specific elevation of serum

amylase • Fever only when infection is present

Trias of DKA

Goals of therapy

• Correct dehydration • Correct acidosis and reverse ketosis • Restore blood glucose to near

normal • Avoid complications of therapy • Identify and treat any precipitating

event

Diagnosis

chest radiogra

ph & Blood Tests

Physical Examinatio

nHistory

CASE ILLUSTRATION

IdentityAF, boy, 14 years 8 months old, came to hospital at March 13rd , 2015

Alloanamnesis

Parents of Patients

Chief complaint

Loss of consciousness since 1 days before came to hospital

Present illness history

Since 3 days SMRs patients vomiting - vomiting . Vomiting every time fed and

watered . Patients complain of difficulty in swallowing and sore on tongue . Appears patches - reddish white patches on the tongue and around the sky - the sky .

Abdominal pain ( + ) , headache ( + ) . Patients also appears frequently drinking and frequent urination . Patients also often wake

up at night to urinate . Urinary volume ± 1gelas bottled water ( ± 200 cc ) each time

urination . Drastic weight loss , but the parents do not know the patient's weight

before. Appetite patients as usual , Chapter soft but not diarrhea , fever ( - ) .

2 months SMRs , patients often consume sugary drinks , such as tea and coffee . Patients often make their own tea and coffee , so that elderly patients do not know the amount of sugar used and how many cups are consumed in a day , but is expected to > 3 cups of tea ( ± 900 cc ) in a day . History of taking drugs ( - )

Present illness history

Since 1 week before admitted to hospital

patient that got cough that has been

happened frequently since a month ago, at

the beginning is non-productive cough,then

starting to be productive cough for the

following week with cream colour sputum. No

one around with cough complaint.

History

Past illness history

• Asthma (-)• there is no

inpatient history on hospital within 48 hours ago

Family illness history

• (-)

Immunization history

• BCG (+)• DPT (+)

Physical examination

General appearance: Moderate

illness

Consciousness: Composmentis

Vital sign:• BP : 110/70• Pulse : 120x/minute,

reguler, strong, adequate • RR : 60x/minute• T : 37,9ºC

Nutritional status: 97%• height : 94cm• weight : 15 kg • upper arm

circumference : 13 cm• Head circumference: 42

Physical examination

Skin : Pale (+), jaundice (-), cyanosis (-), ptekie (-) Head : Normopcephal

Hair : Black, not easily removed

Eyes : • Normal• Conjunctival anemia (+/+)• Sklera ikteric (-/-)• Pupil isokor Φ 2mm/2mm,• Light reflex: direct (+ / +), indirect (+ /

+)

Physical examination

Ears :• Congenital disease

(-)• External canal: secretions

(-), inflammatory signs (-)

Nose:• Nasal flaring (+)

Mouth:• Mucous membranes moist• Intact palate• The tongue is not dirty

Neck:• Lymphadenopathy (-)• Stiff neck (-)

Physical examination

Thorax

• Inspection: subcostal retraction (+)

• Palpation: normal

• Percussion: normal

• Auscultation: Ronkhi (+ /+) in both of lungs

Abdomen

• Normal

Extremity

• Normal

Neurological Status

• Normal

Anamnesis summary

unconscious

Vomiting

Weight lossAbdominal

painPolyuria

Polydipsia

Physical Examination

summary

• Kussmaul• White spot on the

tongue• Abdominal pain

Laboratory examination

• Leukocytosis (18.550/l)

• GDS error (high)• K+ 2,82• Urine pH 6• Urine glucose ++• Urine keton +

Work Diagnosis:Suspek diabeticum ketoacidosis +

hipokalemia

Nutrition Diagnosis:severe nutrition

Suggest examination :C peptideAGDAHba1c

Therapy

IVFD NaCl 0,9% + 20meq KCl 26 tpm makro

Insulin drip 2 unit/hour Ceftriaxon 2x1 gr GDS /hour

Prognosis

Quo ad vitam : Bonam

Quo ad functionam : Malam

Discussion

Diagnosis Therapy

Thank You