Pediatric DKA

Question 1

What are the first 5 interventions that should be performed in an ill-appearing pt?

Answer 1

Oxygen
Cardiac and respiratory monitor
Pulse ox
IV access
Consider EKG/CXR

Question 2

What two tests should be ordered right away in an ill-appearing patient?

Answer 2

Accucheck and UA

Question 3

Always be leery of vomiting (with/without) diarrhea!

Answer 3

WITHOUT

Question 4

A diagnosis of DKA cannot be made without the presence of ____ and ___ (hint: lab findings)

Answer 4

hyperglycemia and acidosis

Question 5

Hyperglycemia is when blood glucose is _____ mg/dL and Acidosis is when venous pH is ____ and/or
bicarbonate is ____ mmol/L

Answer 5

hyperglycemia > 200
venous pH < 7.30
bicarb < 15

Question 6

In terms of venous pH and bicarb levels:
Mild acidosis : pH ____, bicarbonate ____ mmol/L
Moderate acidosis : pH ____, bicarbonate ____ mmol/L
Severe acidosis: pH ____, bicarbonate ____ mmol/L

Answer 6

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

Question 7

During DKA, the liver makes more and more _____ and breaks down ____ b/c the cells are telling it that they are “starving”

Answer 7

glucose; glycogen

Question 8

Fat breakdown results in production of _______

Answer 8

ketoacids

Question 9

Dehydration and poor perfusion leads to _________

Answer 9

lactic acidosis

Question 10

Why do children with DKA take those long deep breaths? What are those breaths called?

Answer 10

“Kussmaul respirations”, to “blow off” more CO2 in an attempt to compensate for metabolic acidosis

Question 11

What is polyuria?

Answer 11

increased volume and frequency of urination

Question 12

Which of the following are sx of acidosis? Hyperglycemia?

Weight loss
Muscle cramps
Polyuria
Altered mental status
Vomiting
Shortness of breath
Headache
New urinary incontinence
Polydipsia
Abdominal pain
Confusion

Answer 12

Acidosis:
Abdominal pain
Vomiting
Shortness of breath
Headache
Confusion
Altered mental status

Hyperglycemia:
Polyuria
Polydipsia
New urinary incontinence
Weight loss
Muscle cramps

Question 13

What are possible PE findings associated with DKA?

Answer 13

Kussmaul respirations
Dehydration (sunken eyes, DMM) signs of shock
Tachycardia
Delayed capillary refill
Abdominal tenderness (non focal or epigastric)

Question 14

Why do kids with DKA get dehydrated?

Answer 14

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 (polyuria) and dehydration
Vomiting can also contribute!

Question 15

Why do kids with DKA have electrolyte imbalances?

Answer 15

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

Hyponatremia and hypokalemia result

Question 16

_____ is the most common cause of diabetes related death in childhood, with children ____ y/o at the greatest risk

Answer 16

DKA (duh); <5 y/o

Question 17

What are the 4 “I”s of DKA?

Answer 17

Insulin (lack)
Indiscretion (of diet)
Infection
Impregnation (or other stressors)

Question 18

When rehydrating a pt with DKA, you want to administer fluids (quickly/slowly). Why?

Answer 18

Slowly, to prevent fluid overload and cerebral edema

Question 19

Consider ordering an EKG to check for ______ secondary to electrolyte imbalances

Answer 19

arrhythmias

Question 20

As part of managing DKA in the ED, how often should you reassess the following?
Accucheck every \_\_\_\_\_
VBG every \_\_\_\_
BMP every \_\_\_\_\_
Neurologic checks every \_\_\_\_\_

Answer 20

Accucheck every 1 hr
VBG every 1-2 hr
BMP every 4 hr
Neurologic checks every hr

Question 21

During rehydration of a pt with DKA, why may some institutions prefer using LR over NS?

Answer 21

LR does not have negatively charged Cl

Question 22

After rehydration of a pt with DKA, what is the next step in tx?

Answer 22

Insulin

Question 23

Do you administer an insulin bolus to all pts with DKA? Why/why not?

Answer 23

No insulin bolus in children! (may increase risk of cerebral edema)

Question 24

Ideally do not want glucose to fall more than ____ mg/dl per hour

Answer 24

100

Question 25

Switch to D5NS when glucose is ____ mg/dL

Why?

Answer 25

<300

Do not want to precipitate an episode of hypoglycemia!

Question 26

There is almost NO clinical benefit of _____ therapy in DKA as it can cause paradoxical CNS acidosis, worsen hypokalemia when administered rapidly, or increase hepatic ketone production.

Answer 26

Bicarb

Question 27

Insulin administration stops further _____ synthesis

Answer 27

ketoacid

Question 28

IV hydration improves ____ ____ and ____ ____

and reverses _____ _____

Answer 28

tissue perfusion and renal function; lactic acidosis

Question 29

Total body ____ is depleted in DKA, as it is excreted in the urine when it binds to the ketoacids. You should administer _____ even if levels appear normal bc once you start giving insulin and correcting the acidosis, this drives the _____ into the cells, lowering the pt’s ____ levels further. (same answer for all blanks)

Answer 29

Potassium

Question 30

What is the most serious complication and most important cause of mortality in children with DKA?

Answer 30

cerebral edema

Question 31

Cerebral edema accounts for ___-___% of all deaths from DKA

Answer 31

60-90%

Question 32

Signs and sx of cerebral edema include…

Answer 32

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

Question 33

Cushing’s triad of cerebral edema….

Answer 33

Bradycardia, increase BP, irregular respirations

Question 34

T/F Cerebral edema can be present before treatment of DKA has begun

Answer 34

True

Question 35

Potential complications of DKA include…

Answer 35

Hyponatremia
Hypokalemia
Acute renal failure
Rhabdomyolysis
Rarely ARDS and pulmonary edema

Question 36

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 which of the following:

A. Insulin bolus of 0.1 units/kg
B. Normal saline or LR bolus 20 ml/kg over 1 hour
C. Sodium bicarbonate 2 meq/kg
D. Mannitol 2 g/kg IV

Answer 36

B. Normal saline or LR bolus 20 ml/kg over 1 hour

Question 37

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 tx the cerebral edema
D. Send her for a stat CT of the head
E. Consult pediatric endocrinology

Answer 37

C. Give mannitol 0.5 mg/kg IV tx the cerebral edema!!