Paeds DKA Flashcards
What are the important principles underpinning DKA management?
Consider underlying cause: non-compliance, new diagnosis, sepsis, other illness
Prevent, seek and treat complications: shock, hypokalaemia, cerebral oedema (overaggressive fluid resus)
How do you determine the fluids required for a paediatric DKA patient?
Estimate deficit + maintenance.
Deficit = % dehydrated x 10 x weight in kg (eg. 5% dehydration = 50 ml/kg)
Maintenance = use 100/50/20 rule (per day) or 4/2/1 (per hour)
Correct over 48 hours using normal saline.
Describe how you would sort out the insulin for DKA patients.
Start at 0.05-1 unit/kg/hr aiming for a BSL fall of <5 mmol/L/hr.
Once BSL <17, change fluids to 0.45% saline + 5% dextrose from 0.9% normal saline.
Describe how you would manage potassium in DKA.
Add KCl 40 mmol/L of maintenance fluid and titrate the KCl replacement, aiming for a [K+] of 4-5 mmol/L. DO not add K+ to bolus fluids.
What would you do if you suspect a DKA patient has cerebral oedema?
Stop fluids, give mannitol 0.5-1 g/kg IV and consider need for intubation + ventilation + CT brain
What is the key life threatening complication of DKA?
Cerebral oedema
What are the biochemical criteria for DKA?
(1) Serum glucose >11 mmol/L, (2) Venous pH <7.3 or bicarb <15, (3) Presence of ketonaemia/ketonuria
What condition may children who have hyperglycaemia and ALOC but no ketonaemia and normal pH have?
Hyperglycaemic-hyperosmolar non-ketotic coma
At what percent of dehydration do patients present with shock?
> 7%
Differentiate mild, moderate and severe DKA.
Mild = pH <7.3, bicarb <15 Mod = pH <7.2, bicarb <10 Severe = pH <7.1, bicarb <5
What are the goals with treatment for DKA?
(1) Correct dehydration
(2) Reverse ketosis, correct acidosis and glucose
(3) Monitor for the complications of DKA
(4) Identify and treat the possible precipitating cause
How do you correct sodium for hyperglycaemia?
Corrected Na = measured Na + 0.3 x (glucose - 5.5) mmol/L
If the sodium does not rise as the glucose falls during the treatment of DKA (or hyponatraemia develops) what could be the cause of this?
Excessive fluid correction
How do you make up the insulin infusion for DKA?
50 units of clear/rapid acting insulin (Actrapid or Huulin) to 49.5 ml of 0.9% sodium chloride to form a 1 unit/ml solution
What are the most important complications of DKA?
Cerebral oedema, hypoglycaemia, hypo/hyperkalaemia, hypo/hypernatraemia, aspiration (if obtunded)
What are the risk factors for cerebral oedema in DKA?
First presentation diabetes, long hx of poor control, age <5 years old
What can be said about the timing and presence of cerebral oedema with DKA?
Some degree of subclinical swelling is present during most episodes of DKA. Clinical cerebral oedema occurs suddenly, usually between 6-12 hours after starting therapy (range 2-24 hours).
What are the signs for cerebral oedema in DKA?
Early: headache, irritability, lethargy, vomiting.
Later: depressed conscious state, incontinence, thermal instability
Very Late: bradycardia, increased BP, respiratory impairment
How is mannitol given in suspected cerebral oedema in DKA?
Mannitol 20% (0.2 g/ml). Dose of 0.5 g/kg IV over 20 minutes (dose range: 0.25-1 g/kg). Repeat if no improvement in 30 mins.
What is the treatment for hypoglycaemia in children w/ DKA?
2 ml/kg of 10% glucose IV bolus + change rehydration fluids to include 10% glucose w/ potassium chloride if required. Continue the insulin.
How much sugar/carb does a 60 ml juice have?
5 grams (for children <25 kg) - this can be given orally for hypoglycaemia
In spite maintenance 10% glucose a DKA patient’s BSLs are still dropping, what should you do?
Do not stop the insulin infusion, however reduce from 0.1 unit/kg/hr to 0.05 units/kg/hr. And even down to 0.03 units/kg/hr
If the acidosis in a DKA patient is not correcting, what is the ddx?
Insufficient insulin to switch off ketosis, inadequate rehydration, sepsis, hyperchloraemia acidosis (due to IVT), salicylates/other substances that cause metabolic acidosis
What are important points about bicarbonate in DKA?
Only appropriate in children with life-threatening hyperkalaemia. May cause paradoxical CNS acidosis and is associated with increased risk of cerebral oedema.
