Case 16: 7 yo with abdominal pain and vomiting

Question 1

Why are kids are higher risk for dehydration than adults?

Answer 1

higher surface area to body mass ratio (more evaporation)

higher basal metabolic rate

Higher percentage of body weight that is water

Question 2

What are the four potential ways to be diagnosed with diabetes?

Answer 2

random fasting glucose of 200 mg/dL with symptoms

fasting glucose over 126

2 hr OGT over 200

A1c over 6.5%

Question 3

What is a typical presentation of DKA?

Answer 3

vomiting, tachypnea, mental status changes, dehydration

with random blood glucose over 200 mg/d:, venous pH less than 7.3 or serum bicarb less than 15 mEq/L and moderate or large ketonuria/ketonemia

Question 4

What happens to the serum potassium levels in DKA?

Answer 4

serum levels can look high, normal or low, but total body potassium will ALWAYS BE DEPLETED in DKA because the acidosis and insulinopenia drives potassium out of the cells into the serum and then you pee it out.

Question 5

What happens to serum sodium levels in DKA?

Answer 5

decreased because of osmotic movement of water into the extracellular space in response to the hyperglycemia and hyperosmolarity (dilutional hyponatremia) as well as from increased renal sodium losses

that’s why it’s important to check the corrected sodium and monitor how it changes with therapy

Question 6

What happens to the serum bicarb levels in DKA

Answer 6

low because of the metabolic acidosis caused by the elevated ketones and lactic acid in the blood

Question 7

What are the three general types of dehydration?

Answer 7

isotonic/isonatremic

Hypotonic/hyponatremic:

Hypertonic/Hypernatremic

Question 8

What’s the issue in isotonic/isonatremic dehydration?

Answer 8

: most common type in children and occurs when sodium and water losses are balanced (acute gastroenteritis and diarrhea)

Question 9

What’s the issue in hypotonic/hyponatremic dehydration?

Answer 9

when sodium losses exceed water losses like when people consume diluted fluids or water in the setting of dehydration, or in adrenal insufficiency

Question 10

What’s the issue in hypertonic/hypernatremic dehydration?

Answer 10

when water loss exceed that of sodium (assciated with the highest mortality)

possible causes include breastfeeding failure, use of inappropriate rehydration sources (like boiled milk) and diabetes insipidus

Question 11

If you correct hypotonic/hyponatremic dehydration too gast, what can occur?

Answer 11

central pontine myelinolysis

Question 12

If you correct hypertonic/hypernatremic dehydration too fast, what can occur?

Answer 12

cerebral edema

Question 13

What kids should be screened for T2CM with a fasting plasma glucose level beginning at 10 yrs of age or at onset of puberty and then every 3 yrs after?

Answer 13

overweight (BMI over 85th percent, weight for height > 85%ile, or weight >120% of ideal for height) with two of risk factors:

1. maternal hx of diabetes or gestational diabetes
2. fam hx of T2DM
3. Race/ethnicity at higher risk
4. Signs of insulin resistance (acanthosis, HTN, HLD, PCOS)

Question 14

What additional screening tests should be done in patients with new type 1 DM?

Answer 14

thyroid function tests yearly

celiac disease screening

Question 15

What should be the first step in managing a patient with deydration?

Answer 15

fluid resuscitation with IV NS at 20 ml/kg over 1 hr

Question 16

What workup should be done for a patient with acute dehydration?

Answer 16

fingerstick glucose
CV monitor continuous
urinalysis
blood gas
BMP

Question 17

After a patient has received adequate fluid rehydration, what should be started?

Answer 17

An insulin drop at 0.1 units/kg/hr (usually start at the same time as you start maintenance IVF)

Question 18

Why should you not give bicarb to a patient in DKA?

Answer 18

you get a paradoxical CNA acidosis and hypokalemia from rapid correction of the serum acidosis, thus you get an increased risk for cerebral edema

Question 19

Should you ever give an insulin bolus in kids?

Answer 19

no - could cause the glucose to drop too rapidly and increase risk for cerebral edema too

Question 20

What dictates the composition of the IV fluids when rehydrating in DKA?

Answer 20

serum sodium concentration

Question 21

What type of fluid is typically used for MIVF in kids?

Answer 21

D5 1/2NS in young kids, D5 NS in older kids

Question 22

How long should a patient be on the insulin drip for?

Answer 22

until the acidosis has resolved (bicarb > 15 or a normal anion gap)

Question 23

Describe the traditional insulin regimen.

Answer 23

2/3 of total dose in the morning (1/3 rapid or short-acting, 2/3 intermediate-acting)

1/6 of total dinner as rapid or short-acting insulin

1/6 of total before bed as intermediate-acting insulin

Question 24

Describe the basal-bolus therapy

Answer 24

50% basal, 50% bolus with the bolus split into three meals

Question 25

How can you get a general esimate of how much basal/bolus insulin to give a kid with DKA?

Answer 25

usually start with 1 unit/kg per day

Question 26

Describe the “honeymoon phase.”

Answer 26

within one month of diagnosis, most pediatric patients with T1DM go through a honeymoon phase in which they have a temporary remission of diabetes where they need very little exogenous insulin