COMPLICATED DKA SINDHU BHARATHI S STANLEY MEDICAL COLLEGE MD POST GRADUATE
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1 COMPLICATED DKA SINDHU BHARATHI S STANLEY MEDICAL COLLEGE MD POST GRADUATE Dr.Shanthi, Professor & Head, Dr. T.S. Ekambaranath Asst Professor, PICU, ISP, Stanley Medical College
2 9yrs male, previously normal child presented with Fever -5days Polyuria,polydipsia x 5 days Vomiting, abdominal pain,lethargy- 4days Breathlessness x 1 day
3 The initial physical examination showed GCS of 8 Pupils unequal Tachycardia, Hypotensive Shock acidodic breathing (respiratory rate 80/minute) Capillary blood sugar high
4 In emergency department After 40 ml/kg of NS bolus Suddenly went for Apnea and Bradycardia CPR started, Adrenaline
5 After CPR - had minimum spontaneous activity Was still in hypotensive shock Adrenaline infusion started Intubated He had second cardiac arrest CPR and adrenaline
6 ED.. 90 MIN Unresponsive Intubated, BAE+, Hypotensive shock NS 10ml/kg given(80ml/kg), Adrenaline 0.5µg/kg/min continued Shifted to PICU for further management
7 IN PICU Intubated, spontaneous efforts+ Hypotensive shock Pupils-unequal, sluggish reaction Blood sugar - 420mg/dl.(sugars reduced with fluids alone)
8 Child had hypospadias. Catheterisedwith difficulty.. anuric
9 PICU 2 HRS Ventilated Considering superadded sepsis bolus hypotension continued(total-120ml/kg 3%NaCl 5ml/kg bolus Adrenaline0.5 µg/kg/min Wide pulse pressure Noradrenaline 0.3 µg/kg/min Antibiotics
10 PICU 5 HOURS Pain responsive(e2vtm4) q Pulse and BP improved Started on maintenance fluids NS 46ml/hr Insulin infusion started 0.05u/kg/hr (after shock correction as BP improved)
11 LAB VALUES ON ADMISSION 6 HOURS UREA CREATININE Na K CBG HIGH 412
12 Urea,creatinine Peritoneal dialysis ( 5 days)
13 Initial improvement rise in urea/creatinine Hemodialysis done on day 7&9
14 Trend of Renal function 120 urea Day 2 Day 4 Day 6 Day 8 Day 10 Day 12 day 19 Peritoneal dialysis continued upto 5(120 cycles) day Hemodialysis done on day 7&9 Given diuretics from day 12 for 3 days
15 Trend of Na, K, CBG hrs 5hrs 12hrs 24hrs 60hrs hrs Na 5hrs 12hrs 24hrs 60hrs CBG
16 METABOLIC ACIDOSIS DAY 1 DAY 2 DAY 3 DAY 4 PH HCO BP 60/40 90/60 90/60 100/70
17 Noradrenaline stopped on day 2 Adrenaline stopped on day 4 Extubated on day 4 SC Insulin,Lispro 0.1u/kg every 3 to 4 hrs started on day 6 (he was on iv fluids till day 5 )
18 OTHER INVESTIGATIONS CBC:TC-12,800.DC-P80,L15,E5.Hb-10.8,Plt-2.8L LFT: Bili-0.6, SGOT 76, SGPT 27, Total protein-6.8, Albumin-3.0 CPK U/L Creatine Kinase levels of > 5000 U/l is related to renal failure? Rhabdomyolysis was noted during the course of DKA which probably contributed to the ARF Urine-high coloured, RBC+ Total cholesterol -115,TGL 302 PS Study: hypochromic, microcytic
19 USG abdomen: Multiple calculi in gall bladder.multiple collaterals replacing Portal vein.multiple collaterals noted in and around Pancreas OGD scopy normal MGE opinion: EHPVO/non bleeder
20 Day14- Started on Plain Insulin.0.3u/kg tid.then changed to twice a day mixed regime on day 20 Shifted to ward on day17 He was discharged in stable condition with good control of blood sugar
21 This case is mainly presented to highlight the multiple complications and deviation in the management from routine DKA protocol
22 INSULIN Dose &time of starting-started 0.05u/kg/hr only after shock had resolved(after 5 hrs) Continued IV Insulin even after correction of acidosis Need for rapid acting Insulin to help titrate sugar in the presence of renal failure.
23 FLUIDS... In DKA fluids not more than 50 ml/kg- in 4 hours, but our patient had hypotensive shock with coexisting sepsis- given bolus upto120 ml/kg Despite fluids his cerebral edema did not worsen as expected.
24 TAKE HOME MESSAGE DKA presenting as hypotensive shock and renal failure is rare. Fluids may have to be titrated based on the individual patient s presentation and response to treatment. Suspect renal failure if there is no improvement of blood sugar
25 Renal failure can be secondary to rhabdomyolysis or shock TEAM EFFORT helps!
26 Acknowledgements Nephrology dept,stanleymedical College Dr.Poovazhagi,Professor,Thanjavur Medical College.MD.Phd
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