An 18-year-old female, newly diagnosed Diabetic (unknown type) 2 months back, presented with a day's history of altered sensorium and fast breathing. This was preceded by generalized malaise, joint pains, and heartburn for 4 days, and progressive weight loss. She was partially treated for 2 days from a clinic with subcutaneous Actrapid 15 IU stat; then, Metformin 500 mg once daily, received Normal Saline 500 mL twice daily, Folate, Ceftriaxone, Metronidazole, Omeprazole, TRAP. A month before the presentation, the patient had stopped taking her medication and was reportedly drinking plenty of drinks that contained processed sugar.
At admission, she was restless and disoriented with a Glasgow Coma Scale (GCS) of 11/15 (E4V2M5). She was afebrile at 36.4 C, had severe dehydration, Kussmaul breathing, mild distress, tachypnea at 30 breaths per minute, and pulse oximetry at 98% on ambient air. She had tachycardia at 112 beats per minute with a blood pressure of 146/75 mmHg.
On investigation, her random blood sugar was 21.2 mmol/L, serum ketones were 3.4 mmol/L, the admission serum: Sodium (Na+) 121 mmol/L, potassium (K+) 4.6 mmol/L, HBA1C 12.1%, CRP 1.69 mg/L, marked Leukocytosis of 16,480 cells/microliter, predominant neutrophilia of 12,840 cells/microliter, Thrombocytosis 419,000 cells/microliter. A respiratory exam revealed coarse crepitations in the right axillary region. The patient received initial fluid resuscitation, and, later admitted to the Highly Dependent Unit (HDU) on the medical ward requiring additional administration of 0.9% normal saline, ceftriaxone, initiation of intravenous rapid-acting insulin infusion, and intravenous KCl at 40 mmol twice a day. With a corrected Na+ level of 128 mmol/L hypertonic saline 150 mmol in 500 mL of Normal saline was initiated to run slowly over 24 hours.
On day 2 of admission, she had Na+ 153 mmol/, K+ 3.7 mmol/L, and serum ketones 2.8 mmol/L. She was switched to half strength Darrow's and hypertonic saline stopped due to hypernatremia. Given the improving levels of consciousness and gradual reduction in RBS and Serum Ketones, she started on subcutaneous rapid-acting insulin. However, on day 4, Na+ continued to rise to 176 mmol/L and by day 5, Na+ was 162 mmol/L.
The patient was discharged on day 8 on mixtard 15 IU pre-breakfast, 10 IU pre-supper, and soluble insulin Actrapid at 6 IU pre-lunch in a stable condition.