Pediatric DKA

Question 1

DKA definition

Answer 1

hyperglycemia over 200 mg/DL AND

acidotic: venous ph less than 7.3 and or bicarb under 15 mmol/L

Question 2

mild dka

Answer 2

ph less than 7.3, bicarb under 15 mmol/L

Question 3

moderate dka

Answer 3

ph less than 7.2, bicarb less than 10

Question 4

severe dka

Answer 4

ph less than 7.1 bicarb less than 5

Question 5

if suspect dka what 2 quick labs do you want to check?

Answer 5

blood sugar and UA (look for glucose and large ketones)

Question 6

underlying pathophys problem causing DKA

Answer 6

pancreas not making enough insulin - seen mostly with type 1 DM

liver thinks cells are staring so starts to create more glucose
breaks down proteins and fats making ketoacids = acidosis and then ..
dehydration and poor perfusion leads to lactic acidosis = 2 kinds of acidosis

Question 7

what 2 kinds of acidosis occur with DKA

Answer 7

lactic acidosis (dehydration / poor perfusion) 
metabolic ketoacidosis (ketoacid production)

Question 8

hyperglycemia sx

Answer 8

polyuria, polydipsia, weight loss, muscle cramps, incontinence

Question 9

acidosis sx

Answer 9

abdominal pain, vomiting, SOB, HA, confusion, AMS

Question 10

kussmaul respirations are..

Answer 10

deep sighing respirations - trying to decrease CO2 in blood to regulate the acidosis back to normal

Question 11

besides kussmaul respirations will see..

Answer 11

dehydration (sunken eyes, dry mucous membranes)
tachycardia
delayed cap refill
abdominal tenderness (nonfocal or epigastric)

Question 12

who is at highest risk for DKA?

Answer 12

kids under 5

Question 13

DKA is most common cause of…

Answer 13

diabetic death in childhood

Question 14

why do kids with DKA get dehydrated?

Answer 14

osmotic diuresis and vomiting

Question 15

why do kids with DKA have electrolyte imbalance?

Answer 15

ketoacids bind NA and K which gets excreted then in urine

this leads to hyponatremia and hypokalemia

Question 16

what are the four Is of DKA precipitants

Answer 16

insulin lack
indiscretion (dietary)
infection
impregnation (or other stressors)

Question 17

how often check a DKA pts.. 
accucheck? 
VBG 
BMP 
neurological check?

Answer 17

accuchekc and neurological check every hour
VBG every 1-2 hours
BMP every 4 hours

consult endocrinology and critical care

Question 18

first step of DKA treatment

Answer 18

IV hydration: NS bolus or LR bolus

20 ml/kg over 1 hour

then do LR at 2 times the maintaince ivf rate

Question 19

concern with correcting dehydration too quickly

Answer 19

cell swelling and cerebral edema

Question 20

step 2:

Answer 20

insulin IVF bolus

.05-.1 U/kg/hr regular insulin

**for kids no insulin bolus - cerebral edema

Question 21

ideally don’t want glucose levels to drop more than __ per hour

Answer 21

100mg/dl

Question 22

when glucose is finally under 300mg/dL what should you switch do?

Answer 22

D5NS

Question 23

step 3… reverse the acidosis .. how?

Answer 23

insulin administration - stops ketoacid production

IV hydration - reverses lactic acidosis

Question 24

after 4-6 hours of the normal saline at 2X the maintainence rate switch to…

Answer 24

.45% saline with electrolytes

Question 25

for a 15 kg child maintaince IV fluid rate would be…

Answer 25

50 ml/hr

Question 26

bicarb is usually not given unless..

Answer 26

arterial ph is under 6.9, hypotension shock arrhythmia or severe hyperkalemia

Question 27

how do you administer bicarb?

Answer 27

1-2 mEq/kg over 1 hour (sodium bicarb)

Question 28

signs of cerebral edema

Answer 28

HA, decrease in LOC (level of consciousness), slow HR with increase in BP, change in pupils

Question 29

risk factors for cerebral edema

Answer 29

younger they are, new onset DM 
severe acidosis 
high BUN 
use of sodium bicarb in tx 
overaggressive fluid replacement

Question 30

how to treat cerebral edema

Answer 30

lower IVF infusion rate
mannitol .5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min

have to consider intubation if airway at risk

Question 31

other weird DKA complications

Answer 31

rhabdomyolysis
ards
pulmonary edema

Question 32

t/f no insulin bolus in kids

Answer 32

TRUE

Question 33

when should you be worried about monitoring / replacing K+

Answer 33

around the 4 hour mark