diabetic ketoacidosis in kids

Question 1

5 things to do:

Answer 1

• oxygen
• cardiac and respiratory monitor
• pulse ox
• IV access
• Consider EKG/CXR

Question 2

DKA: definition

Answer 2

• Hyperglycemia >200 and…

- Acidosis: venous pH<7.3 and/or bicarbonate <15

Question 3

DKA categories:

Answer 3

Mild: pH < 7.30, bicarbonate < 15 mmol/L
Mod: pH < 7.20, bicarbonate < 10 mmol/L
Severe: pH < 7.10, bicarbonate < 5 mmol/L

Question 4

most often what is the problem?

Answer 4

pancreas not making enough insulin (type1)

Question 5

Symptoms of hyperglycemia:

Answer 5

Polyuria: increased volume and freq of urination
Polydipsia: increased thirst
New urinary incontinence
Weight loss
Muscle cramps

Question 6

symptoms of acidosis:

Answer 6

Abdominal pain
Vomiting
Shortness of breath
Headache
Confusion
Altered mental status

Question 7

Kussmaul respirations:

Answer 7

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

Question 8

physical exam findings:

Answer 8

• kussmaul respirations
• dehydration (sunken eyes, dry mucous membranes)
• tachycardia
• delayed capillary refill
• abdominal tenderness (confocal or epigastric)

Question 9

why do kids with DKA get dehydrated?

Answer 9

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

Question 10

why do kids with DKA have electrolyte imbalances?

Answer 10

Ketoacids bind Na+ and K+ and they are excreted in the urine

Hyponatremia and hypokalemia result

Question 11

DKA precipitants, the I’s

Answer 11

• insulin lacking
• indiscretion (dietary)
• infection
• Impregnation or other stressors

Question 12

treatment:

Answer 12

Correct dehydration
Correct acidosis and reverse ketosis
Restore normoglycemia
Correct electrolyte imbalances
Avoid complications of treatment
Identify and treat precipitating event

Question 13

ED management of DKA:

Answer 13

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

Question 14

ED tx step 1:

Answer 14

• IV hydration
• initial NS bolus or LR bolus 20 ml/kg over 1 hour
• next: LR at 2x MIVF rate

Question 15

take home point 2:

Answer 15

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

Question 16

treatment step 2:

Answer 16

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

Question 17

step 3 tx:

Answer 17

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

Question 18

step 4 tx:

Answer 18

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

Question 19

cerebral edema tx:

Answer 19

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

Question 20

cerebral edema s/s:

Answer 20

Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils

Question 21

high risks for cerebral edema:

Answer 21

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

Question 22

take home points:

Answer 22

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)

Question 23

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

Answer 23

B

Question 24

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

Answer 24

C