diabetic ketoacidosis in kids Flashcards
5 things to do:
- oxygen
- cardiac and respiratory monitor
- pulse ox
- IV access
- Consider EKG/CXR
DKA: definition
- Hyperglycemia >200 and…
- Acidosis: venous pH<7.3 and/or bicarbonate <15
DKA categories:
Mild: pH < 7.30, bicarbonate < 15 mmol/L
Mod: pH < 7.20, bicarbonate < 10 mmol/L
Severe: pH < 7.10, bicarbonate < 5 mmol/L
most often what is the problem?
pancreas not making enough insulin (type1)
Symptoms of hyperglycemia:
Polyuria: increased volume and freq of urination Polydipsia: increased thirst New urinary incontinence Weight loss Muscle cramps
symptoms of acidosis:
Abdominal pain Vomiting Shortness of breath Headache Confusion Altered mental status
Kussmaul respirations:
Learn to recognize this sign of acidosis!!!
Deep sighing respirations
Commonly mistaken for respiratory distress due to pneumonia, asthma, or anxiety
It is the body’s way of compensating for metabolic acidosis
Decreases CO2
physical exam findings:
- kussmaul respirations
- dehydration (sunken eyes, dry mucous membranes)
- tachycardia
- delayed capillary refill
- abdominal tenderness (confocal or epigastric)
why do kids with DKA get dehydrated?
Osmotic diuresis
Kidneys normally reabsorb glucose and water
In uncontrolled diabetes, the kidneys are overwhelmed by excess glucose
The excess glucose keeps water in the renal tubules
This causes increased urination and dehydration
Vomiting
why do kids with DKA have electrolyte imbalances?
Ketoacids bind Na+ and K+ and they are excreted in the urine
Hyponatremia and hypokalemia result
DKA precipitants, the I’s
- insulin lacking
- indiscretion (dietary)
- infection
- Impregnation or other stressors
treatment:
Correct dehydration Correct acidosis and reverse ketosis Restore normoglycemia Correct electrolyte imbalances Avoid complications of treatment Identify and treat precipitating event
ED management of DKA:
ABCs, cardiac monitor, vital signs, accucheck IV access (2 is best) BMP, VBG, UA, +/- CBC Consider EKG Accucheck every 1 hr VBG every 1-2 hr BMP every 4 hr Neurologic checks every hr Consultation with endocrinology & critical care
ED tx step 1:
- IV hydration
- initial NS bolus or LR bolus 20 ml/kg over 1 hour
- next: LR at 2x MIVF rate
take home point 2:
Correction of dehydration and hyperosmolarity must be slow to avoid rapid shift of water from the extracellular space to the intracellular space!!!!
Cell swelling
Cerebral edema
treatment step 2:
After initial IVF bolus
Insulin infusion 0.05-0.1 U/kg/hr regular insulin
No insulin bolus in children!!! (may increase risk of cerebral edema)
Ideally don’t want glucose to fall more than 100 mg/dl per hour
Switch to D5NS when glucose is < 300 mg/dL
step 3 tx:
Treat and reverse the acidosis:
Insulin administration
Allows glucose into cells and stops the cycle!!
Stops further ketoacid synthesis
IV hydration
Improves tissue perfusion and renal function
Reverses lactic acidosis
step 4 tx:
Next 4-6 hrs: NS with 40 mEq/L K+ (20mEq/L KCl and 20 mEq/L KPhos)
Rate is 2x maintainence rate
After 4-6 hrs: Switch to 0.45% saline with electrolytes
cerebral edema tx:
Reduce rate of IVF infusion
Mannitol 0.5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min
Consider intubation if cannot protect airway
cerebral edema s/s:
Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils
high risks for cerebral edema:
Very young New onset DM with first time DKA Severity and duration of acidosis before treatment High BUN Overaggressive fluid replacement Use of sodium bicarbonate
take home points:
Always be leery of vomiting without diarrhea
Recognize Kussmaul respirations
Careful fluid resuscitation
No insulin bolus in kids
Monitor and replace K+
Monitor neurological status during treatment
Recognize signs of cerebral edema (altered mental status, dilated pupils, decreased heart rate with increased BP)
A 14 year old F with type I diabetes is brought in by her mother for vomiting and malaise. Her mother reports she has a history of poor compliance with her insulin and she is not sure if she has been using her insulin. On exam, she is alert with dry lips with a HR of 120 and a BP of 110/60. Her bedside glucose is 450 mg/dl and her VBG shows a pH of 7.1. Your first step in management is:
A.Insulin bolus of 0.1 units/kg
B.Normal saline or LR bolus 20 ml/kg
C.Sodium bicarbonate 2 meq/kg
D.Mannitol 2 g/kg IV
B
The patient in the prior question becomes increasingly lethargic and you are unable to arouse her. You also note pupillary dilation bilaterally. Her RR is regular at 36, and she is maintaining an O2sat of 98% on RA. You immediately should:
a. Stop the insulin drip
b. Increase the insulin drip rate
c. Give mannitol 0.5 mg/kg IV
d. Send her for a stat CT of the head
e. Consult pediatric endocrinology
C
