This is the case of a pediatric patient with diabetic ketoacidosis whom symptoms were undetected on her initial visit to ED.
A 2 year old previously healthy girl first presented to ED with vomiting for 2 days. The vomiting was non projectile with no blood or bile, no diarrhea, without preceding trauma or fever. She was diagnosed as acute gastroenteritis and discharged home. 12 hours later, she presented again with lethargy and rapid breathing. On further questioning, she had increase in fluid consumption and polyuria since the course of the illness. Initial assessment revealed drowsiness, lethargy, pale, Kussmaul’s breathing, moderate dehydration with estimated fluid deficit of 7.5%. She was normotensive with BP 110/60 mmHg (MAP 70), tachycardic (HR 150/minute), SpO2 96% and normothermic (temperature 37.2°C). Her blood glucose level was 37 mmol/L with severe acidosis (venous pH 6.8, HCO3 too low, lactate 2.6, BE -28) and serum ketone 4.7. Full blood count shows leukocytosis with white cell counts of 17.3 (lymphocytes 50%, neutrophils 43%), platelets of 590 and hemoglobin of 12.9 g/dL. Blood urea was high (6.6), however liver enzymes and electrolytes were all within normal limit. Initial saline bolus of 100 ml over the first hour was started, followed by 7.5% correction using 16 ml/hour of saline over 48 hours and maintenance using half saline mixed with 1g KCL at a rate of 40ml/hour. Insulin infusion was started at a rate of 0.1 unit/kg/hour and was transferred to PICU.
DISCUSSION & CONCLUSION
Diagnosing DKA in pediatric patient can be challenging, especially when the staff is unfamiliar with such case as they usually present with vague symptoms without known history of diabetes. This unfortunate case demonstrates the importance of high level of suspicion and considering glucose as the sixth vital sign in sick child.