CCP 348 Endocrine Emergencies Flashcards
1
Q
main differences in management between peds DKA and adult DKA
A
- adults require large volumes of IVF as part of initial resuscitation. large volumes of fluid are harmful in peds DKA (cerebral edema). Fluid resuscitation in peds DKA is more conservative, drawn out over time .
- The second important difference is the administration of insulin. While insulin is bloused in the adult patient, insulin boluses are contraindicated in the pediatric patient with DKA.
- Monitoring and correction of K+ is heavily stressed in the adult patient with DKA. In children however, IV fluids are started prior to insulin administration, and a K+ level will always be available prior to initiating insulin.
- With respect to the acidosis, bicarbonate is indicated in adult patients who are profoundly acidotic. In contrast, sodium bicarbonate is not indicated in children outside of an arrest situation
2
Q
discuss Sodium Bicarbonate in Pediatric DKA
A
- Bicarb is not indicated for routine management of peds DKA
- Canadian Diabetes Association (CDA) peds guidelines say “consider in cardiac arrest”
3
Q
DKA PATHOPHYSIOLOGY
💵💵💵MONEY SLIDE💵💵💵
A
- metabolic effects of insulinopenia
- ↓ glucose uptake into muscle, fat, liver
- ↑ gluconeogenesis, ↑ glycogenolysis, ↑ lipolysis, ↑ ketogenesis
- hyperglycemia, obligate diuresis
- ↑ stress hormones aggravate situation
- metabolic acidosis: ketones, lactate
- huge losses of H2O, Na+, K+, HCO3–, Pi
4
Q
BCCH DKA PROTOCOL 2019: GENERAL PRINCIPLES
💎💎💎MEGA PEARL💎💎💎
A
- 10–20 mL/kg fluid push up front, repeat if CVS status not improved
- assume 5–10% dehydration (7% for most)
- nice, even, balanced rehydration over 24–36 h
- use of 0.45–0.9% NaCl‐containing fluids
- avoid use of bicarbonate
- no insulin in the initial 1–2 h of treatment
- continuous insulin infusion, glucose to match
- continued use of the “two‐bag” method
5
Q
BCCH DKA PROTOCOL 2019 BASICS
A
- on admission: weight, vitals, assessment and stabilization
- first 30–60 minutes: fluid resuscitation
- 60 min–36 h: fluid replacement, insulin infusion, addition of glucose
- throughout: careful monitoring, reassessment, titration of fluids, electrolytes, glucose, insulin
6
Q
BCCH DKA PROTOCOL: 1st 60 MINUTES
A
- give 1st bolus of NS 10 mL/kg IV over 30 min (initial resuscitation)
- most really sick patients require a 2nd NS bolus of 10 mL/kg IV over 30 min
- the sickest patients may require even more NS to stabilize HR and ↑ peripheral perfusion
7
Q
best methods for assessing dehydration in kids
🧙🧙🧙ESOTERIC WISDOM🧙🧙🧙
A
prolonged capillary refill (>1.5–2 sec) abnormal skin turgor abnormal respiratory pattern weak pulses cool extremities tachycardia
8
Q
shitty methods for assessing dehydration status in kids
A
dry mouth
urine output
blood pressure
weight
9
Q
mild dehydration in infants (% BODY WEIGHT)
A
5%
10
Q
moderate dehydration in infants (% BODY WEIGHT)
A
10%
11
Q
severe dehydration in infants (% BODY WEIGHT)
A
15%
12
Q
mild dehydration in kids (% BODY WEIGHT)
A
3%
13
Q
moderate dehydration in kids (% BODY WEIGHT)
A
6%
14
Q
severe dehydration in kids (% BODY WEIGHT)
A
9%
15
Q
BCCH DKA PROTOCOL: 60 MINUTES–36 HOURS
A
- begin even rehydration over 36 h, estimating 10% dehydration:
o 5–10 kg BW: 6.5 mL/kg/h
o 10–20 kg BW: 6 mL/kg/h
o 20–40 kg BW: 5 mL/kg/h
o >40 kg BW: 4 mL/kg/h, max 250 mL/h - start with NS + 40 mEq KCl/L, assuming patient is urinating
- at 60–120 min after start of 1st fluid bolus, begin insulin infusion:
o 0.05–0.1 Units/kg/h - when BG is <25 mmol/L and falling >5 mmol/L/h, add dextrose to IV fluids using the “two‐bag” method
16
Q
BCCH DKA PROTOCOL: 60 MINUTES–36 HOURS
describe the process for titrating therapy according to the coveted “two bag method”
🧙🧙🧙Esoteric Wisdom!!🧙🧙🧙
A
when BG is <25 mmol/L and falling >5 mmol/L/h, add dextrose to IV fluids using the “two‐bag” method
- aim to keep BG in the ~8–12 mmol/L range by titrating the rates of the two Bags A and B
- a general rule is to make changes of approximately 10–20% of the total rate every hour
- if the patient’s BG is lower than desired, despite maximal dextrose infusion from Bag B, you may (in order of safety):
o cut the insulin infusion rate by ~25%, provided the acidosis is correcting
o give the patient a small amount (1–2 mL/kg) of juice or 2–4 dextrose tablets (being mindful of the overall fluid balance)
o change the insulin Bag C to D10/NS
o in institutions with intensive‐care capabilities, consider placing a central line and
using a higher concentration of dextrose (e.g. D20) in Bag B - at 4–6 h after initial fluids and if corrected Na+ is ≥145 mmol/L, stable or increasing:
o switch Bag A to ½NS + 40 mEq/L KCl
o switch Bag B to D10/½NS + 40 mEq/L KCl - if unable to get K+ >3.5 mmol/L with IV fluids: consider PO/NG KCl
- may give 50% of K+ as phosphate (order by the mmol of K+)
o may prevent ensuing hyperchloremia, but no clear evidence of benefit - bicarbonate: rarely if ever needed
17
Q
ongoing monitoring for peds DKA
A
- BG by meter q30–60 min (may need lab BG if >30 mmol/L)
- Na+, K+, Cl−, HCO3−, anion gap, urea, creatinine, venous pH q2–4 h
- Ca2+, Mg2+, Pi q2–4 h if giving phosphate
- β‐hydroxybutyrate (preferably) or urine ketones q2–4 h
- neurovital signs/GCS q30–60 min
- corrected Na+ = [measured Na+ + 0.36×(BG−5.6)]
- active osmolality = [BG + 2×(Na++K+)]
18
Q
MECHANISMS OF CEREBRAL INJURY (peds DKA)
A
- vasogenic edema: leakage across altered BBB
- hypoxia
- cerebral hypoperfusion/reperfusion
- neuroinflammation (IL‐6, etc.)
- ketones (altered BBB)
- hypocapnia (↓ cerebral blood flow) - other possible factors:
- role of Na+–H+ antiporter‐3 (insulin) and Na+–K+–Cl− cotransporter‐1
- continued absorption of H2O from GI tract
- vasopressin, atrial natriuretic peptide
- cellular edema: osmotic shifts across cell membrane
19
Q
cerebral injury epidemiology (peds DKA)
A
- can be present at diagnosis before treatment
- usually occurs in first 12–24 hours of treatment
- DKA still has ~0.5–1% risk of cerebral injury
- ~25% mortality rate, ~35% serious morbidity rate
- 70–80% of diabetes‐related deaths in kids <12
- greatest contributor (~50%) to mortality of DKA, not hyperglycemia or shock
- subclinical CI with subtle sequelae may be frequent in DKA
20
Q
cerebral injury signs and symptoms (peds DKA)
A
- severe headache
- change in sensorium: irritability, confusion, inability to arouse
- dilated pupils, papilledema, cranial nerve palsies
- posturing, incontinence
- decreased O2 saturation
- Cushing’s triad (bradycardia, hypertension, irregular respirations)
21
Q
cerebral injury treatment (peds DKA)
A
- elevate head of bed
- reduce fluid rate by ⅓
- mannitol 20% 0.5–1 g/kg (2.5–5 mL/kg) IV over 15 min
- HTS 3% 3–5 cc/kg IV over 15 min
- intubate if pending respiratory failure
- mild hyperventilation
- no known role for dexamethasone
- early Dx and Rx improve outcome
22
Q
complications of DKA
A
- hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia
- hyperchloremic acidosis (NaCl fluid loading))
- hypoglycemia
- peripheral venous, dural sinus, basilar artery thrombosis
- pulmonary embolism, pulmonary edema, PTX, aspiration pneumonia, ARDS
- rhabdomyolysis
- acute pancreatitis
- intracranial hemorrhage, cerebral infarction
- acute kidney injury
