A child with DKA..

History of Diabetes Ketoacidosis :

Patient is admitted in Paediatric ward in Bed -406


Particulars of patient:

Name: Sangita Patel Age: 13 years/Female
Address: Siraha
Religion: Hindu
Education: 9 Class
Occupation: Student
DOA: 15th Feb, 2007 ( 5 days ago )
DOE: 19th Feb, 2007
MOA: OPD

Chief complains :-

Increased thirst – 2 months
Frequency of urination – 2 months
Increased food intake – 2 months
Generalized weakness – 1 week


History of Present Illness :-


—According to the patient’s mother, she was apparently well before 2 months, then she had small swelling on the back of the right knee which healed after 1 week . Then, she gradually developed increased thirst .
—Then, she developed frequency of micturition max. up to 5 times at night, increased volume, light orange in colour, frothy but no foul smelling . Appetite for food was increased with no significant change in weight.
—There was also history of fatigue for 1 week. The patient is unable to do routine activities on her own.
—There is also a h/o fever for 2 days which was acute in onset, continuous, max. temp recorded was 103°F and associated with chills , rigors and sweating and relieved on medication.
—There is no h/o vomiting, diarrhea, abdominal pain, burning micturition, seizure and no loss of consciousness.

History of Past Illness :-

No significant past medical or surgical history.

Birth History :-

No significant ante-natal, intra-natal or post-natal history.

Immunization History :-

All vaccines were taken as per National EPI schedule.

Developmental History :-

—The growth of the child was as per normal developmental milestones. She studies in Class 9 with average performance in class. By my interpretation her intelligence is average.

Personal History :-

—Bowel – Normal
—Appetite- Increased
—Sleep- Increased
—Urine- Increased

Dietary History :-

—Total calorie intake: 1300 k cal/day
—Total calorie needed: 2050 k cal/day (WHO)
—Calorie deficit: 750 k cal/day



Family History :-

There is no significant disease running in the family.

Thank You



And Live with Passion

(the purpose of this post was to let us know how the patient of DKA actually presents , and especially when she is child of 13 years.Hope it served its only purpose.)

DIABETES KETOACIDOSIS (DKA)

It is an Acute complication of Diabetes Mellitus(DM).

It is a hyperglycemic state of body . Other is Hyperosmolar, Hyperglycemic Non-Ketotic Syndrome(HHNS).( in latter vomiting is presented in history)

Triad of DKA:

1. Hyper-glycemia
2. Metabolic- Acidosis
3. Ketosis

Other hyper-glycemic states -

DM
HHNS
Impaired Glucose Tolerance
Stress Hyper-glycemia

Other metabolic Acidotic states -

Lactic Acidosis
Hyper-Chloremic Acidosis
Salicylism
Uremic Acidosis
Drug-induced Acidosis

Other ketotic states

Ketotic Hypo-glycemia
Alcoholic Ketosis

precipitatin factors
infections
intercurrent illnesses
psychological cause
omission or inadequate insulin therapy
Non-compliance
Newly diagnosed DM
USE OF CONTINUOUS SUB-CUTANEOUS INSULIN INFUSION DEVISES (CSII)
Pathogenesis

Insulin deficiency
Increased counter-regulatory hormones
Dehydration

Catabolic state is predominant over anabolic state.

For dx-

plasma glucose > 250 mg/dL
Serum bicarbonate>15 mEq/L
pH<7.3
Ketonemia ( Nitroprusside ) at dilution 1:2
Anion- gap Acidosis

tx-
iv fluid
insulin replacement
bicarbonate and potassium infusion


(Ya, i have a question too, why hyper-chloremic acidosis is seen in DKA )

TAKE CARE
I HOPE THIS LITTLE INFO WAS WORTH READING ..........

LIVE WITH PASSION
Sushant-passion

[flirt]

Because bicarbonate is decreased which is replaced by chlorine.

[kehi garnuchha]

thanks a lot Sushant passion,,keep on posting like this,,,,,,,,,,,,



if less bicarbonate is replaced by chlorine,
why there is an ion gap acidosis?
if chlorine replaces,where does it come from?

[Hero]

Originally Posted by Sushant-passion

Dietary History :-

—Total calorie intake: 1300 k cal/day
—Total calorie needed: 2050 k cal/day (WHO)
—Calorie deficit: 750 k cal/day

how do u calculate the total calorie intake?

[flirt]

Originally Posted by kehi garnuchha

if less bicarbonate is replaced by chlorine,
why there is an ion gap acidosis?
if chlorine replaces,where does it come from?

Diabetic ketoacidosis is often not a “pure” high anion-gap acidosis at presentation, and it almost invariably goes through a “non-gap” phase during recovery. Metabolic acidosis may be of two types1: acidosis with an increased anion gap (usually due to organic acids), and acidosis with a normal anion gap, usually due to hyperchloremia and called hyperchloremic acidosis.
Hydration status was directly related to the degree of retention of unmeasured anions: ie, patients with the highest degree of volume depletion were most likely to have a large anion gap.
In patients with diabetic ketoacidosis, the increase in anion gap usually parallel with the fall in bicarbonate. However, during recovery, these patients all developed a hyperchloremic type of metabolic acidosis.
The mechanism of hyperchloremic acidosis in diabetic ketoacidosis is best understood by considering the consequences of adding a large quantity of beta-hydroxybutyric acid to the extracellular fluid, as occurs early in the development of diabetic ketoacidosis. Initially, each hydrogen ion combines with a bicarbonate, “destroying” it to produce CO2 and water. The accompanying anion (in this case beta-hydroxybutyrate) is retained in the plasma and is an “unmeasured” anion.
However, because the clearance of ketoacid anions by the kidney is relatively high, as long
as volume depletion is avoided and the glomerular filtration rate is adequate, many of these unmeasured anions will be excreted in the urine along with accompanying cations (sodium or potassium).
This wasting of ketone salts produces a contraction of extracellular fluid volume and signals the kidney to retain dietary or infused sodium chloride. As a result, the bicarbonate in the extracellular fluid remains at a reduced level while the anion gap is diminished, due to a relative hyperchloremia.
In some patients in whom ketoacidosis develops more slowly, there may be large losses of these anions in the urine, with increasing acidosis (reflected by the low bicarbonate) that is not reflected by an accompanying increase in the anion gap.

[Khushboo]

Originally Posted by Hero

how do u calculate the total calorie intake?

What does the person normally eats everyday is at first asked and then from the list the calorie value is noted.
For example:
1 cup cooked rice - 175 cals
Cooked daal 1 Tsp - 8 cals
coffee milk 1 cup - 45 cals
Egg 1 - 80 cals
* Add to list as per your need

After adding all the total calorie what you get is the total calorie intake of that person

Now you have to know that whether this total calorie intake meets the requirement for that age or not, and if not what is the calorie deficiet?

Calorie requirement per day
0-6/12- 120 kcal/kg/day
7/12-12 - 100 kcal/kg/day
1 year - 1000 kcal/day
> 1 year - 1000 + (age-1) X 100 kcal/day

Calorie deficiet= Total calorie requirement- Total calorie intake of that person

[Hero]

Oh great...I really can't remember 1 cup of tea gives this much of calories, 1 cup of coke, 1 cup of coffee, 1 glass of water, 1 'thal' of rice, 1 bowl of daal, saag, aalu, achar etc etc...good way to calculate...nice !!!

[SUMAN-SAJAN]

Thanks Sushant .....

[Sarensa]

Great work guys and thankx a lot. Keep on posting such useful posts.