Case Report

Diabetic Ketoacidosis on Type 1

Diabetes Mellitus
Ega Gumilang Sugiarto
1112103000046
Supervisor: Dr. dr. Bina Akura, SpA
Patients ID
Name : An. ZN

MR : 1456497

Age : 13 year - 3 months

Date of birth : February 26th 2004

Address : Jl. Batu Ampar V, Kramat Jati, East Jakarta

Admission date : August 25th 2016
CHIEF COMPLAINT
Referred to Fatmawati GH due to:
RBG > 370 on another hospital
Short of breathness
Vomitting
 6 hours a go
1 year ago
Admitted to RS Mampang due to
Admitted to RS Polri
With chief complaint Short of
the same complain
breathness and Vomitting Shortness of Breathness, not
RBG corelation with posisition and

Current Illness History activities, fast and deep

Diagnose with DM Type I
Referred to
Eats >3x/day
Vomitting, 4x/day, fluid and Fatmawatifor
Drinks >3 L/day
last meal, 250cc, lost appetite further management
Micturates >8x/day
Body itch (-) RBG was 370g/dL, got insulin
Blurr vision (-) inject in ER RBG 303 g/dL
Patient was hospitalized, and No pain, no fever, no cough,
give Novorapid (10-10-10) and
levemir (1x20) use daily
fatigue
Referred to Fatmawati Hospital
Past Illness
This is the 2nd time with the same complain
Shortness Of Breath (+)
Vomitting (+)
Asma (-)
History of Gastritis (-)
Allergy (-)
Family History
Her Father was had DM type II with oral
medications
Another family history with same complain (-)
History of Pregnancy and Birth
ANC 4x
USG 1x baby in good condition
Fever (-), vaginal discharge (-), rash (-), high
blood glucose (-)
Spontaneous birth, G4, 9 mga
BW 2400gr, BL 50cm
Spontaneous cry
Nutrition
Exclusive breastfeeding til 6 m/o
Breastfeed til 2 y/o
Before diagnosed
4-5 big meal/day
Often snack, not count
After diagnosed
3 big meal/day
2 snack/day
Measured
Vaccination
Hepatitis B :3x
Polio :4x
BCG :1x
DTP :3x
HiB :3x
Measles :1x
Developmental Status
Roll back : 4 mo
Sit wo support : 6 mo
Specific words : 12 mo
Reads words : 48 mo
Elementary school : 6 yo, never repeats grade
Physical Examination
General condition : Sever Ill
Consciousness : Somnolen
Vital sign :
BP: 141/83 mmHg
HR: 153x/min;
RR: 48 x/min;
Temp: 36,9o C
Physical Examination
Anthropometry
Weight : 46 kg
Height : 150 cm

Weight/Age 46/48 x 95.83% = normal weight

Height/Age 150/158 x 94.93% = normal height
Weight/Height 46/47 x 97.8% = normal weight

Interpretation well nourished

 Physical Examination
Organ Findings
Head Normocephalic, black hair, even distribution
Eyes Pale conjunctivae (-), icteric sclerae (-), VA OD 6/60 OS 6/60
Ears Mucus (-), serumen (-), TM intact
Nose Mucus (-), deviation (-), edema (-) flare nose (+)
Mouth/Throat Lips mucosa is dry, hyperemia (-), T1/T1
Neck Lymph node enlargement (-) muscle contraction (+)
 Physical Examination
Pulmo Findings
Inspection Symmetrical shape and movement, intercostal retraction (+)
Palpation Lesion -/-, mass -/-, emphysema -/- vocal fremitus +/+
Percussion Sonor
Auscultation Vesicular +/+, rhonchi -/-, wheezing -/-
 Physical Examination
Heart Findings
Inspection Ictus cordis unseen
Palpation Ictus cordis felt, thrill (-)
Percussion Left heart border : ICS V, 1 finger medial to left midclavicle line
Right heart border: ICS IV, right parasternal line
Auscultation S1-S2 regular, murmur (-), gallop (-)
 Physical Examination
Abdomen Findings
Inspection Flat, scar (-), mass (-)
Auscultation Bowel sound (+)
Percussion Timpanic, shifting dullness (-)
Palpation Tender, Liver and spleen not palpable, tenderness (-)
 Physical Examination
Extremity Findings
CRT >2 seconds
Oedema No oedema
Toe cold
Sianosis No sianosis
Work Up
Full Blood
Chemical blood
Electrolyte
Full Urinalisys
Rontgen Thorax
Blood Gas Analysis
Laboratorium
Pemeriksaan Nilai Rujukan SGOT 17 0-34
Hb 16.0 11.7-15.5 SGPT 13 0-40
Ht 51 33-45
Leukosit 29.7 4.5-13.5
UREUM 30 0-48
Trombosit 403 184-488 CREATININ 0.6 0.0-0.9
Eritrosit 5.88 3.80-5.20 GDS 405 60-100
VER 86.5 80.0-100.0 CK 60 <=140.00
HER 27.1 26.0-34.0 CK-MB 40 7-25
KHER 31.4 32.0-36.0
RDW 12.8 11.5-14.5
TROPONIN-I <0.01 <0.02
 URINALISA
Warna Kuning Kuning
Kejernihan Jernih Jernih
Urobilinogen 0.2 <1.00
pH 6.968 7.370-7.440
Albumin Positif 1 Negatif
PCO2 11.5 35.0-45.0
Berat Jenis 1.030 1.005-1.030
PO2 191.7 83.0-108.0
Bilirubin Negatif Negatif
BP 760.0 Keton Positif 3 Negatif
HCO3 2.6 21.0-28.0 Nitrit Negatif Negatif
SaO2 98.6 95.0-99.0 pH 5.5 4.8-7.4
BE -27.5 -25-2.5 Leukosit Negatif Negatif
TOTAL CO2 2.9 19.0-24.0 Darah/Hb Positif 1 Negatif
Glukosa Positif 2 Negatif
Urin/Reduksi
SEDIMEN URINE
Epitel 1.5 Pria <=5.7 dan
Na 136 135-147
wanita <=45.6
K 5.75 3.10-5.10
Leukosit 0.6 Pria <=9.2 dan
Cl 115 95.0-108.0 wanita <=39
Keton Darah 3.30 0.00-0.60 Eritrosit 1.4 Pira<=13.1 dan
Golongan O/Rh(+) wanita <=30.7
Darah Silinder Negatif Negatif

Kristal Negatif Negatif

Bakteri 0.9 Pria<=11.4 dan
wanita <=385.8
Lain-Lain Negatif Negatif
Expertise : Cor and Pulmo in normal condition
DIAGNOSIS
Diabetic ketoasidosis on DM type I

DIFFERENTIAL DIAGNOSIS
HHS
Lactat acidosis
PROGNOSIS
Ad Vitam : Dubia ad Bonam
Ad Sanationam : Dubia ad malam
Ad Functionam : Dubia ad malam
TREATMENT
Non Medika Mentosa :
Diabetes meal 1320 kkal, give it 3 times eatdan 2-3 times snacks
O2 nasal canool 3lpm
Hospitalize in PICU
Medika Mentosa :
IVFD Loading Nacl 0.9% 400cc fluid in hour
Continue with kristaloid Nacl0.9% 170ml/jam
Insuin 110 unit in NaCl 0.9% 100ml/24 jam
Bicnat correction 190 mEq + 400ml NaCl 0.9% in 8 hours
Continue Bicnat 190 mEq +400ml NaCl 0.9% in 16 hours
Px GDS /hour
Antibiotic Cefotaxim 4x1g IV
Topic Theory
 Definition
Diabetes Mellitus (DM) is a chronic metabolic disease
characterized by hyperglycemia as a cardinal biochemical
feature.
Type 1 results from deficiency of insulin secretion because of
pancreatic -cell damage;
Type 2 diabetes mellitus (T2DM) is a consequence of insulin
resistance

Britta MS, Nicholas J. Diabetes Mellitus in Children. Dalam: Nelson Texbook of Pediatrics. Edisi 20. Saunders Elsevier. 2016. h.2760-90
 Diabetic Ketoasidosis

Diabetic Ketoacydosis is an acute condition which could

make people die and its the complication from chronic
disease Diabetes Melitus. Here is the severity of the disease:

Mild : pH vein 7,2-7,3 dan bicarbonat <15 mEq/L

Moderate : pH vein 7,1-7,2 dan bicarbonat <10 mEq/L
Severe : pH vein <7.1 dan bicarbonat < 5 mEq/L
Epidemilogy
Clinical Manifestation

Pankaj Seth et al. Clinical Profile of Ketoacidosis: A prosprctive study in a tertiary care hospital.Journal of clinical
and diagnostic research.NCBI.2015
Clinical Manifestation (2)

Pankaj Seth et al. Clinical Profile of Ketoacidosis: A prosprctive study in a tertiary care hospital.Journal of clinical
and diagnostic research.NCBI.2015
Dehidration stage
Clinical Diagnosis
Diagnostic Criteria for Diabetic Ketoacidosis
(DKA)
Blood glucose (mg/dl) > 250
Arterial pH < 7.3
Serum bicarbonate (mEq/l) < 15
Moderate degree of ketonaemia and
ketonuria
Pathophysiology
KAD
vs
HHS
Prevention

Trachtenbarg DE. Diabetic Ketoacidosis. American Family

Physician 2005,;71(9):1705-14
Risk Of Treatment

Paulo Ferrez Collett-Solberg. Diabetic Ketoacidosis in children:review of pathophysiology and treatment with the use of the two bags system. J Pediatr (Rio J) 2001; 77(1): 9-16:
Discussion And case Analysis
Discussion (Anamnesa)
From anamnesa we could get that he got Diabetes
Melitus Type I since 1 year ago. Already got the
Insulin Inj. Uncontrolled RBG. Kusmaul Breath
(fast and deep), vomiiting (+), family history with
Diabetes Melitus and also this is the second time
patient got the same complaint. There is still no
chronic complication of DMT-1 on this patient.
Discussion (Physical Examination)
From physical examination we could get that he
got low consciousness, high frequency of RR,
high frequency of HR, flare nose (+), muscle
neck contraction (+), intercostal contraction (+),
CRT>2, and also the toes was cold.
Discussion(Laboratory exmaniation)
From laboratory, the point that support the
diagnosis is, we got leukositosis (29.7), high
Blood Glucose (405), low pH(6.968), low HCO3
( 2.6), low PCO2(11.5), BE (-27.5), and total CO2
(2.9). Blood keton (3.3)
From Urinalisa, we got Albumin (+), keton (++
+), blood (+), and glucose reduction (++)
Treatment Discussion
Rehidration Calculation (1)
Suspected the patient could be with syock and
severe KAD
Loading dose 10-20ml/kgbb
10 x 46 = 460cc loading (1/2 hour)
Rehidration Calculation (2)
- calculate dehidration stage : % (A)
Dehidrasi berat count with 10%
- calculate fuild defisite: (A x BB (kg) x 1000 = B mL)
10x46 x 1000 = 4600ml
- calculate 48 hours of maintenance fluid : C mL
2020x2 = 4040ml
- calculate Total fluid needed in 48 hours: (B+C mL)
4600+4040 = 8600ml/48jam
- Calculate the drip in one hour: (B+C)/48 jam = mL/jam
8600/48 = 179ml/jam 170ml/jam
Insulin Calculation
0.1 IU/KgbBB/jam 0.1 x 46 = 4,6 IU/jam
110.4 IU/24 jam

Attention with Potassium count in Blood

(contraindication with K <3.5)
Metabolic Acydosis correction
Rumus Koreksi NaHCO3 :
NaHCO3 = BEx0.3xBB
NaHCO3 = -27.5 x 0.3 x 46
NaHCO3 = -379.5

dosage in 8-12 hours then continue

the rest
Diabetes Meal
Age 13 yo
Basal Calory 48x25 = 1200 kkal
Bed Rest +10% = 10% x 1200 = 120
Total Calory 1200+120 = 1320kkal/24 jam

Diabetes meal 1320 kkal, divided into 3 times eat dan

2-3 snack times, the choosen time should be the same
day by day
Advice
Daily Blood Glucose
Daily blood keton or Urinalysis
Blood Gas Analysis
Electrolyte post treatment
It should be change into insulin subcutan when
the patient already stable with keton (-)
Reference
Konsensus Nasional Pengelolaan Diabetes Melitus tipe I. UKK ENDOKRINOLOGI ANAK DAN REMAJA, IKATAN DOKTER ANAK INDONESIA WORLD
DIABETES FOUNDATION. Badan Penerbit Ikatan Dokter Indonesia. 2009
Aksara B. Karakteristik Ketoasidosis Diabetik Pada Anak. KSM Anak RSUP Fatmawati. Jakarta
Pardede O Sudung, dst. Tatalaksana Berbagai Keadaan Gawat Darurat pada Anak. Pendidikan Kedokteran Berkelanjutan LXIV.Departmen ilmu kesehatan
anak FKUI-RSCM. Jakarta.2013
Britta MS, Nicholas J. Diabetes Mellitus in Children. Dalam: Nelson Texbook of Pediatrics. Edisi 20. Saunders Elsevier. 2016. h.2760-90
Jose RL, Bambang T, Aman BP. Diabetes Mellitus. Dalam: Buku Ajar Endokrinologi Anak. Edisi 1. Ikatan Dokter Anak Indonesia. 2010. h.122-190
Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar stase: ISPAD Clinical Practice
Consensus Guidelines 2014 Compendium. Pediatric Diabetes. 2014;15:154-179
Syahputra. Diabetik Ketoacidosis. Fakultas Kedokteran Universitas Sumatra Utara. USU digital library.2003
American Diabetes Association. Hyperglicemic crises in patients with diabetes mellitus. Diabetes care 2002;25(1), supplement 1:S100
ISPAD. Consensus guidelines. ISPAD consensus guidelines for the management of type 1 diabetes mellitus in childhood and adolescent. 2000.
Wallace TM, Matthews DR. Recent advance in the monitoring and management of diabetic ketoasidosis. QJ Med 2004;97: 773-80.
Wira Gotera, Dewa Gde Agung Budiyasa. Penatalaksanaan Ketoasidosis Diabetik (KAD). SMF Ilmu Penyakit Dalam FK UNUD. RSUP Sanglah Denpasar.2
Mei 2010.
Paulo Ferrez Collett-Solberg. Diabetic Ketoacidosis in children:review of pathophysiology and treatment with the use of the two bags system. J Pediatr
(Rio J) 2001; 77(1): 9-16:
Trachtenbarg DE. Diabetic Ketoacidosis. American Family Physician 2005,;71(9):1705-14
.Beatrice C Lupsa, Silvio E.Inzucchi. Diabetic ketoacisodis and Hyperosmolar Hyperglicemic Syndrome. Springer Science and Bussiness Media.New
York.2014.
Pankaj Seth et al. Clinical Profile of Ketoacidosis: A prosprctive study in a tertiary care hospital.Journal of clinical and diagnostic research.NCBI.2015.
Thank You
 Chronic Complication
Makroangiopati
Penyakit jantung koroner
CVD
Mikroangiopati
Neuropati DM
skrinning untuk mendeteksi adanya polineuropati distal yang simetris dengan melakukan
pemeriksaan neurologi sederhana (menggunakan monofilamen 10 gram). Pemeriksaan ini
kemudian diulang paling sedikit setiap tahun (
Retinopati DM
Nefropati DM
Diagnosis nefropati diabetik ditegakkan jika didapatkan kadar albumin >30 mg dalam urin 24
jam pada 2 dari 3 kali pemeriksaan dalam kurun waktu 3- 6 bulan, tanpa penyebab albuminuria
lainnya
Bicarbonate
Studies of patients with a pH level of 6.9 or higher
have found no evidence that bicarbonate is
beneficial,and some studies have suggested
bicarbonate therapy may be harmful for these
patients.advises giving no bicarbonate if the pH level
is greater than 6.9. Because there are no studies on
patients with a pH level below 6.9, giving bicarbonate
as an isotonic solution still is recommended.