DKA

Question 1

When does DKA occur

Answer 1

At dx
When ill 
During growth spurts / puberty
Insulin omission 
Cannula dislodges from insulin pump

Question 2

Clinical features

Answer 2

Abdo pain
Polyuria + polydipsia + dehydration
Kaussmaul resp
Acetone smelling breath
Vomiting
Hypovolaemic shock 
Drowsiness / coma / death

Question 3

Recognition

Answer 3

> 11 and symptoms of DKA - admit to acute paeds facility

At hosp test BM and capillary blood ketones

Question 4

Dx

Answer 4

Acidosis (<7.3)
Ketonaemia (blood beta-hydroxybutyrate > 3) OR ketonuria (++)

Severe DKA = DKA + pH < 7.1

Question 5

Initial management

Answer 5

Inform senior, inform family of dx

Record LOC, vital signs, vomiting, dehydration and bodyweight

Morbidity and mortality is from cerebral oedema - aim is for very slow and gentle correction

Question 6

Management of alert patient

Answer 6

Oral fluids and SC insulin

Only if patient is alert, not nauseated or vomiting and not clinically dehydrated

Monitor for resolution of ketonaemia and acidosis

Question 7

Management of unwell pt - fluids

Answer 7

Fluid (0.9% NaCl until plasma glucose < 14 - ensure fluid contains 40mmol/L KCl unless renal failure)

Aim to correct over 48 hours with maintenance + deficit

Deficit: assume 5% deficit in mild / moderate DKA, assume 10% deficit in severe DKA

Maintenance: < 10kg = 2mL/kg/hour, 10-40kg = 1 mL/kg/hour, > 40kg = 40 mL/hour (fixed)

Question 8

Management of unwell pt - insulin

Answer 8

IV insulin infusion 1-2 hours after IV fluid therapy:

Soluble insulin infusion 0.05-0.1 units/kg/hour
Start SC insulin 30 mins before stopping IV insulin

Question 9

Complications of DKA

Answer 9

Cerebral oedema - headache, agitation, irritability, unexplained fall in HR or BP - if present immediately tx with mannitol (20%, 0.5-1 g/kg over 10-15 mins)

Hypokalaemia (<3) - suspend insulin infusion, discuss with senior

VTE

Question 10

Blood glucose tests

Answer 10

Fasting: Normal < 6.0, Diabetic >7.0
Random: Normal < 7.0, Diabetic > 11.1

OGTT:
Normal: Fasting < 6.1, 2 hr < 7.7
Diabetic: Fasting > 7.0, 2 hr > 11.1

Question 11

Dx

Answer 11

Symptomatic + one abnormal BM

Asymptomatic + two abnormal BM