Paeds PACES

Question 1

DKA management

Answer 1

A-E resuscitation

• A: if reduced GCS, insert airway + consider NG if unconscious and/or recurrent vomiting
• B: 100% oxygen via face mask
• C: IV cannula + take bloods. Cardiac monitor for T waves (hyperkalaemia). Measure BP + HR

Call for senior support - Med Reg, Paediatrics, ICU/HDU outreach?

Rehydration + fluid monitoring (urinary catheter)
- NOT SHOCKED: 10 ml/kg 0.9% sodium chloride bolus over 60 minutes.
SHOCKED: 20 ml/kg bolus of 0.9% saline over 15 minutes
- Re-assess + give further boluses of 10ml/kg if required - up to total 40ml/kg
- ensure that every 500 ml bag of fluid contains 20 mmol potassium chloride (40 mmol per litre) - K+ will fall once insulin started

Insulin to correct hyperglycaemia

• start infusion 1-2 hours after IV fluids
• e.g. infusion of 0.05 or 0.1 units/kg/hour
• aim for reduction of plasma glucose no faster than 5mmol/L/hour (avoid Cerebral oedema)

Start saline + dextrose once Glucose lower e.g. 14 - but continue insulin

+ consider bicarb if ph<7.0, life-threatening hyperK+, acidosis with impaired myocardial contractility

Switch to oral fluids when vomiting stops
Switch to sub cut insulin when able to eat

Question 2

DKA Ix results

Answer 2

Blood gas:
Metabolic acidosis
Low normal CO2 - Kussmaul breathing

Ketonuria

High capillary glucose

Question 3

DKA Criteria

Answer 3

Mild DKA – venous pH 7.2- 7.29 or bicarbonate < 15 mmol/l. Assume 5% dehydration

Moderate DKA – venous pH 7.1-7.19 or bicarbonate < 10 mmol/l. Assume 7% dehydration

Severe DKA – venous pH less than 7.1 or serum bicarbonate < 5 mmol/l. Assume 10% dehydration