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Paeds: Acute Presentation > Diabetic ketoacidosis > Flashcards

Diabetic ketoacidosis Flashcards

1
Q

What are 8 symptoms and signs of diabetic ketoacidosis?

A
  1. Smell of ketones on breath
  2. Vomiting
  3. Dehydration
  4. Abdominal pain
  5. Hyperventilation due to acidosis (Kussmaul breathing)
  6. Hypovolaemic shock
  7. Drowsiness
  8. Coma and death
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2
Q

What are 6 earlier signs of T1DM that may be in the history of a child presenting with DKA?

A
  1. Polydipsia (excessive drinking)
  2. Polyuria
  3. Weight loss
  4. Enuresis (secondary - inability to control urination)
  5. Skin sepsis
  6. Candida and other infections
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3
Q

What are 7 essential early investigations to perform in suspected diabetic ketoacidosis?

A
  1. Blood glucose (>11.1mmol/L)
  2. Blood ketones (>3.0mmol/L)
  3. U+Es, creatinine (dehydration)
  4. Blood gas analysis (severe metabolic acidosis)
  5. Evidence of a precipitating cause e.g. infection (blood and urine cultures performed)
  6. Cardiac monitor (ECG) for T-wave changes of hypokalaemia
  7. Weight (compare with recent clinic weight to ascertain level of dehydration)
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4
Q

What are the 6 key stages of management of diabetic ketoacidosis?

A
  1. IV fluids
  2. Insulin - after IV fluids running for 1 hour
  3. Potassium replacement and monitoring
  4. Acidosis
  5. Re-stablish oral fluids, subcutaneous insulin and diet
  6. Identification and treatment of an underlying cause
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5
Q

How should fluid resuscitation be performed in diabetic ketoacidoss? 6 aspects

A
  1. initial resuscitation with 0.9% saline (10ml/kg)
  2. dehydration should then be corrected gradually over 48 hours
  3. initial rehydration fluids need to be taken into account in calculating fluid requirements
  4. 0.9% saline with 40mmol/L KCl recommended for first 12 hours
  5. add 5% glucose when blood glucose <14mmol/L
  6. after 12 hours, if plasma sodium level stable, 0.45% saline/5% glucose with 40mmol KCl recommended
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6
Q

What is the recommended initial fluid resuscitation in DKA?

A

0.9% saline, 10ml/kg

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7
Q

Over what time period should dehydration be corrected in DKA and why?

A

over 48 hours; rapid rehydration may lead to cerebral oedema

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8
Q

What fluids are recommended for the first 12 hours following DKA resuscitation?

A

0.9% saline with 40mmol/L KCl then add 5% glucose when blood glucose <14mmol/L

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9
Q

What fluids are recommended after 12 hours following initiation of treatment of DKA?

A

if plasma sodium level stable, 0.45% saline/5% glucose with 40mmol/L KCl

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10
Q

When should you start giving 0.5% glucose with fluids?

A

when blood glucose <14mmol/L

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11
Q

What are 5 important things to monitor when giving fluid therapy in DKA?

A
  1. Fluid input and output
  2. Blood glucose (hourly)
  3. Blood ketones (1-2 hourly)
  4. Electrolytes, creatinine, acid base status (2-4 hourly)
  5. Neurological state
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12
Q

How frequently should the following be monitored when giving fluids in DKA:

  1. blood glucose
  2. blood ketones
  3. electrolytes, creatinine, acid-base status?
A
  1. hourly
  2. 1-2 hourly
  3. 2-4 hourly
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13
Q

What are 3 things that you must consider if a patient is shocked in DKA?

A
  1. transfer to PICU
  2. Central venous line (CVP)
  3. Urinary catheter
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14
Q

What are 2 reasons why an NG tube may be used for acute gastric dilatation in DKA?

A
  1. Vomiting
  2. Depressed consciousness
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15
Q

When should an insulin infusion be started in DKA?

A

1 hour after IV fluids started running

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16
Q

In what form should an insulin infusion be given in a child in DKA?

A

0.1 units/kg per hour - do not give a bolus

aim for gradual reduction of blood glucose

17
Q

When should you stop the insulin infusion in DKA?

A

change to solution containing 5% glucose when blood glucose has fallen to 14mmol/L - to avoid hypoglycaemia

18
Q

How frequently should blood glucose be monitored when treating DKA?

A

hourly

19
Q

How much potassium is given when correcting DKA?

A

40 mmol/L given with 0.9% saline for first 12 hours

40mmol/L with the 0.45% saline/5% glucose after 12 hours

20
Q

Why is potassium given when correcting DKA?

A

although initial plasma potassium may be high, due to displacement from cells in exchange for hydrogen ions, it will fall following treatment with insulin and rehydration

(insulin causes potassium to move into cells)

must be started as soon as maintenance fluids started

21
Q

Why does the way that potassium is given in children with DKA differ from how it is given in adults?

A

children are assumed to have normal renal function and greatest risk is from total body potassium depletion

22
Q

What are 2 things that are done to monitor potassium during the treatment of DKA?

A
  1. 2-4 hourly plasma potassium measurements
  2. Continuous cardiac monitoring for effects of hypokalaemia
23
Q

How long should you monitor potassium for when treating DKA?

A

until plasma potassium is stable

24
Q

What type of acid-base derangement is present in DKA and how should it be managed?

A
  • Metabolic acidosis
  • Bicarbonate avoided unless child is shocked
  • Acidosis will correct with fluid and insulin therapy
25
Q

What is can sometimes precipitate DKA?

A

intercurrent infection

26
Q

How should the precipitating factor of DKA be managed?

A
  • if infection: may have fever. DKA causes neutrophilia but not fever
  • antibiotics may be indicated
27
Q

What are 9 types of diabetes in children?

A
  1. Type 1 - destruction of pancreatic beta-cells by an autoimmune process
  2. Type 2 - insulin resistance folloewd later by beta cell failure
  3. Maturity onset diabetes of the young
  4. Drugs e.g. corticosteroids
  5. Pancreatic insufficiency e.g. CF, iron overload in thalassaemia
  6. Endocrine disorders e.g. Cushing syndrome
  7. Genetic/ chromosomal syndromes e.g. Down and Turner
  8. Neonatal diabetes: transient and permanent secondary to defective B cell function
  9. Gestational diabetes
28
Q

What 3 things are done to confirm a diagnosis of Type 1 diabetes and what are 2 further tests that can be used if there is uncertainty?

A

usual tests:

  1. Random blood glucose (>11.1 mmol/L)
  2. Glycosuria
  3. Ketosis

If any doubt:

  1. Fasting blood glucose (>7 mmol/L)
  2. Raised glycosylated haemoglobin aka HbA1c

(tolerance test rarely required)

29
Q

What are 5 features that would make you susect T2DM in a child rather than T1?

A
  1. Family history
  2. Severely obese children with signs of insulin resistance
  3. Acanthosis nigricans (velvety dark skin on neck or armpits)
  4. Skin tags
  5. Polycystic ovary phenotype in teenage girls
30
Q

What are 10 things that must be covered in the intensive educational programme for parents and child with diabetes?

A
  1. Basic understanding of pathophysiology
  2. Injection of insulin technique and sites
  3. Blood glucose monitoring and ketones when unwell
  4. healthy diet
  5. exercise
  6. sick day rules to prevent DKA
  7. recognition and treatment of hypos
  8. where to get advice 24 hours a day
  9. help available from voluntary groups e.g. local groups or diabetes UK
  10. psychological impact of lifelong condition with short and long term complications
31
Q

What are 5 types of insulin and examples of each?

A
  1. human insulin analogues - rapid acting e.g. lispro/Humalog, glulisine/Apidra or aspart/Novorapid
  2. Long-acting insulin analogues e.g. Detemir/Levemir, glargine/Lantus
  3. Short actings soluble human regular insulin e.g. ActRapid and Humulin S
  4. Intermediate acting insulin e.g. Insulatard and Humulin I
  5. Predetermined preparations of mixed rapid or short acting and inter-mediate acting insulins with 25% or 30% short-acting components
32
Q

What is the onset of action of short-acting soluble human regular insulin and the peak? What is the duration?

A

30-60 min, peak 2-4 hours

duration up to 8 hours

33
Q

What is the onset and peak of intermediate-acting insulin?

A

onset 1-2 hours, peak 4-12 hours

34
Q

How should insulin be injected?

A

Into subcutaneous tissue of anterior and lateral aspects of the thigh, the buttocks, and the abdomen

Rotation of sites to prevent lipohypertrophy or lipoatrophy

Gently pinch up skin and inject at 45 degree angle

35
Q

What are the 2 most common insulin regimens that children are started on?

A
  1. Continuous subcutaneous insulin pump
  2. Basal-bolus multiple daily injections
36
Q

How does the basal-bolus regimen work?

A
  • rapid acting insulin e.g. Lispro, Glulisine, Insulin Aspart given before each meal (bolus)
  • Long acting insulin e.g. Glargine or Determir given in late evening and/or before breakfast to provide insulin background (basal)
37
Q

What is the target range for blood glucose and when does this apply?

A

aim for insulin between 4 - 7 mmol/L before meals

38
Q

What are 2 things that children having a hypo can take?

A
  1. Oral glucose gels e.g. Glucogel - buccal absorption
  2. Glucagon IM injection kit - hormone triggering break down of stored glucose and release into blood

Paeds: Acute Presentation (14 decks)

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