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Abstract: Disorders of acid-base balance should be taken seriously, even more so in diabetic ketoacidosis-induced disorders. The 15-year-old female patient in this article had acute gastroenteritis triggered by eating unclean food, followed by symptoms such as thirst and dyspnea. Based on the patient’s symptoms and auxiliary examinations, she was diagnosed with acute diabetic ketoacidosis and was immediately admitted to the hospital. Under the treatment of fluid replacement, acid correction, glucose lowering, ketone elimination and anti-infection, the patient’s condition was controlled and all indicators improved.
Basic information】Female, 15 years old
Disease Type】Diabetic ketoacidosis, shock
Hospital】The Second Hospital of Harbin Medical University
Date of Consultation】March 2011
Treatment plan]: Rehydration, volume expansion, pressure-raising treatment (saline, amino acids) + acid correction (sodium bicarbonate) + hypoglycemia, anti-ketosis (insulin) + anti-infection (amoxicillin, sulbactam) + catheterization + potassium supplementation (potassium chloride)
【Treatment period】5 days
Treatment effect】The condition was controlled and all indicators were improved
I. Initial consultation
The patient was 15 years old, brought to the hospital by her family for 2 hours due to unconsciousness, and was previously in good health. Two days before the onset of the disease, she had nausea, vomiting, epigastric pain and dilute watery stools after eating spoiled food. The patient’s blood pressure was measured immediately after the visit and was found to be 70/40 mmHg, heart rate of 120 beats/min, oxygen saturation of 92%, and body temperature of 38°C. After asking the family, the patient’s usual blood pressure was 90/60 mmHg. Based on these examinations, the patient was initially considered to have decompensated metabolic acidosis, which is a type of acid-base balance disorder and may be caused by diabetic ketoacidosis. Acidosis may be caused by diabetic ketosis.
II. Treatment history
Considering the patient’s young age and serious condition, we immediately explained to the family that the patient’s condition was critical and recommended emergency admission to the hospital, and improved urine routine, blood biochemistry, and blood routine tests. The results were as follows: blood leukocytes 23.7×10^9/L; urine routine: urine protein 1+, urine sugar 4+, urine ketone body 4+; blood biochemistry: creatinine 168umol/L, urea 12.22umol/L, blood glucose 49.43mmol/L, hydrogen carbonate 3.6mmol/L, AG 44.2mmol/L. The patient was rapidly treated with saline and amino acids for volume expansion, rehydration, and blood pressure. The patient was treated with fluids, rehydration, and elevated blood pressure, and the acidosis was corrected with intravenous sodium bicarbonate, and insulin was pumped intravenously to lower glucose and eliminate ketones. Give patients catheterization and potassium chloride rehydration treatment to prevent hypokalemia after massive rehydration. Blood gases were monitored every 1-2 hours, mainly to observe the changes in pH, blood glucose, and blood ion levels after drug therapy, and blood pressure was also monitored. Considering that the patient’s shock was associated with hypovolemia, the treatment was based on volume expansion and rehydration. When the patient received about 1500 ml of intravenous fluid, blood pressure returned to the usual normal level, urine output was above 40 ml per hour, and shock was corrected. Blood glucose decreased at a rate of 5 mmol/L per hour. After about 8 hours of glucose-lowering treatment, blood glucose decreased to 12 mmol/L, the patient was fully awake and could eat water, and saline was replaced with glucose plus insulin to continue the elimination of ketone therapy. Urinary ketone bodies were monitored daily and were negative for 3 consecutive days, after which intravenous ketone elimination therapy was stopped and subcutaneous insulin therapy was started. The patient’s condition was basically stable after 5 days of hospitalization.
III. Treatment effect
The patient was given these therapeutic measures, and at the time of rapid rehydration for about 2 hours, blood pressure was the first to return to its usual normal level without the use of vasoactive drugs and remained stable, and hourly urine output reached normal levels. In addition, the patient’s consciousness gradually turned clear, and about 8 hours after the steady decrease of blood glucose, the consciousness completely returned to normal, and he could eat and drink. After 5 days of hospitalization, the patient’s body temperature was normal, no gastrointestinal discomfort, urine ketone body and urine glucose were normalized on recheck, blood leukocytes dropped to 5.2×10^9/L, blood urea creatinine were normalized, fasting glucose 6.3mmol/L, and the patient was discharged.
IV. Notes
We are very glad that the patient’s condition was controlled and all the indexes were improved. However, the patient had no previous history of diabetes, and the first attack appeared as an emergency, which should be taken seriously by parents. After discharge, the patient should use insulin to control blood glucose for a long time, monitor blood glucose level regularly, and adjust the insulin dosage dynamically in strict compliance with the doctor’s prescription, and avoid reducing or stopping the dosage by oneself. It is recommended to regularly review blood glucose and adjust insulin dosage at the endocrine clinic. In daily life, it is necessary to control the diet and weight, reduce the intake of fat and protein to prevent new ketone bodies from appearing in the body due to fat metabolism, which can aggravate the disease. In addition, considering the young age of the patient, parents should supervise and collaborate more often. If diarrhea, lethargy or other uncomfortable symptoms occur on weekdays, seek medical attention as soon as possible.
V. Personal insight
Diabetic ketoacidosis has a certain lethality if not treated in time, so early detection and timely treatment are necessary and the prognosis is generally better. And respiratory tract infection and gastrointestinal infection are common triggers of diabetic ketoacidosis, and shock can occur in severe cases. When patients are found to have nausea, vomiting, thirst, deep breathing, dry skin and lips, weakness around the body, pain in the whole abdomen, drowsiness and other uncomfortable symptoms, it is important to seek medical diagnosis and treatment as soon as possible. Since the symptoms of acidosis have certain characteristics, especially deep and large breathing, it is important to be alert and seek medical diagnosis as soon as possible once they appear. For adolescents who have had diabetes in the past, they cannot change their glucose-lowering regimen at will, and when they have a cold or diarrhea, they must be treated as early as possible to prevent diabetic ketoacidosis.