DKA Flashcards
Biochemical crtieria
> 11 glucose
venous pH < 7.3 OR bicarb >15
Ketonaemia >3
Risk factors DKA
<2 years - new diagnosed
Delay diagnosis
Insulin omission
Poor metabolic control
Prev episodes DKA
GE with persistent vomitting
Eating disorder - diabulimia
Challening social and family circumstanced
Adolescents
Pump therapy
What type of insulin is given in pump therapy?
Short acting insulin
Mild DKA parameters
mild - pH <7.3, <15mmol bicarb
Severity of DKA?
mild - pH <7.3, <15mmol bicarb
Moderate DKA severity
pH<7.2, bicarb >10
Severe DKA severiy
pH < 7.1, bicarb >15
Counterregulatory hormones to insulni
Glucagon
Cortisol
Growth hormone
Catecholamines
Aseess for in DKA
GCS
BP, pulse, CRT
Degree of dehydration
Acidotic respiration
Vomitting
BG, ketones, blood gas, U/E, FBC, cultures
Suspect sepsis if fever or hypothemia, hypotension, refractory acidosis or lactic acidosis
What does hypotnesion in DKA signa;?
Cerebral oedema
Clinical signs and symptoms DKA
Dehydration
Tachycardia/ypnoea
N+V
Deep, sighing resp
Semll acetone
Abdo pain
Confusion
Goals of therapy
Cprrect dehydration
Correct acidosis and reverse ketosis
Slowly correct hyper-osmolay
Restore BG to near normak
Monitor complications of DKA and its treatment
Identify and treat and precipitating event
When insert AW in DKA
When child camatose
When insert NG tube
Why monitor T waves in DKA?
Hyperkalemia - tall tented
What is a late sign of cerebral oedema?
Papilloedema
Treatment DKA
10mls/kg blus over 30 mins
Sec 10ml/kg bolus and reassess may need second
Insulin at 0.05 units/kg/hr
Continue basal insulin
Max weight 75kg/98th percentile for age
Segar Holliday formula
Child fluid allowance
What do with pump therapy in DKA?
STOP - short acting insulinn
When consider reducing insulin in KDA?
BG < 14
otassium level in forst 24 hours
Over 5.5 - nil
3.5-5.5
Under 3.5 - central line anaaesthetist high concentration
Insulin has aldosterone effect
Pushes potassium into cell
Treatement expectation of DKA
Reduction of blood ketone concentation at least 0.5mmol/L/hr
Bicarb rise by 3mmol/l/hr
Cap blood glucose falls by 3mmol/L/hr
Na+ corrects by 4-5 mmol/L/he
What monitor in DKA
Headahce
Innapropriate slwoing HR
Recurrnec of vomitting
Change in neurological status - restlessness, irritability, increased drwosy, incontinence
Specific neurological signs - cn palsies, abnormal pupillary repsosne
If acidosis is not correctin
Insiffucient insulin to switch off ketones
inadequate resuscitation
Sepsis
Hypercholoramic acidosis - drop saline conc
Slaicyclate or other perscription or recreational drugs
Hypoglycaemia cut off in neonates
2.6
If BG <4 what do you use
10% dextrose 2mls/kg bolus
Reduce insulin
Hypoglycaemia in normal child
3.6
What is hypoglycaemia in child with diabetes
4
Complications DKA
Cerebral oedema
Hypo
Hypokalemia
Sepsis
Myoglobinuria
Spiaration oneumonai
Thrombosis
Pancereatitis
Patient risk factors for hypoglycaemia?
Hypoglycaemia unawareness
History of previous hypos
Defective glucose counterregulation
Long duration of diabetes
Erratic insulin absorption
<5-7 years
Behavioural risk factors for hypoglycaemia
Dietary inconsistency
Prlonged fasting
Missed meal or snack
Strenous exercise - also increases sesntiivtity to insulin
Medical risk factors for hypoglycaemia
Drug side effects - beta blockers (block signs of hypos)
Dosing errors
Unpredicatable insulin kinetics
Inappropriate insulin distribution
Autonomic symtpoms of hypoglycaemia
Hunger
Swaeting and clammy hands
Anxiety
Pallor
Nausea
Trembling or shaking
Neuroglycopenia symptoms of hypoglycaemia
Dizziness/confusion
Headache/irritability
Blurred/bright vision
Slurred speech
Sleep/gazed eyes
Weakness
Lack of concentration
Feeling warm or hot
Naughty/aggressive behaviour
Nightmares/seizures
Risk factors at diagnosis or during treatment of DKA for more severe presentation
Greater hypocapnia at presentation
Increased urea at presentataion
More severe acidosis at presentation
A marked early decrease in serum effective osmolality
Attenuated rise in serum sodium conc or early fall in glucose-corrected sodium during therapy
Greater volumes of fluid in first 4 hours
Administration of insulin in first hour of fluid
Features of cerebral oedema
Abnormal motor or verbal response to pain
Decorticate or decerebrate posture
Cranial nerve palsy (III, IV, VI)
Abnormal neurogenic resp pattern
Abnormal neurogenic respiration in cerebral oedema features
High RR
Grunting
Cheyne-Stokes breathing
Apnoeas
Neuroprotective measures
Elevate head 30 degrees
Intubation if impending resp failure
Maintain BP + tmep
CO2 low end of nomrla
Consider crainial imaging
