Pediatric DKA (Tucker) - MT

Question 1

A 7 year old male who weighs 50 pounds presents to the ED with 2 day history of abdominal pain, no fever, had URI 2 weeks ago. Patient has been drinking well and has been waking at night to void. On physical exam, cap refill is delayed and there is a significant weight change from an appointment 2 weeks ago. Random glucose is 600 mg/dL and Urinalysis reveals elevated glucose and ketones in urine.

What is the Dx?

What is the initial treatment you would give? (3 things)

Answer 1

• Dx: Diabetic Ketoacidosis
• Place IV and give:
  1. 20ml/kg of 0.9NS bolus admin (stabilize CV status)
  2. Administer 0.1 units of Insulin per hour
  3. Give potassium infusion

Question 2

Following initial treatment treatment of DKA with bolus fluid, insulin, and potassium, what molecule should you be concerned about replenishing in the patient?

When this molecule drops below _____ , you should start infusion to keep the patient stable.

Answer 2

• blood glucose levels
• 200 mg/dL

Question 3

What lab tests should you obtain immediately after initial treatment of a pediatric patient with DKA? (x3)

Answer 3

• BMP (Na, K, Cl, BUN, Cr, Gluc)
• CBC
• HbA1C
• Blood gas (VBG more gentle than ABG)

Question 4

Maintenance fluids by weight:

1. Per 24 hours?
2. Per 1 hour?

Answer 4

1. first 10 kg = kg x 100 ml/kg/day, next 10 kg = kg x 50 ml/kg/day, kg above 20 kg = kg x 20 ml/kg/day
2. Hourly rate = 4 / 2 / 1 ml/kg/hour (same pattern)

Question 5

You should stop IV insulin and fluids when:

1. Anion gap is less than _______
2. Venous pH is greater than ______ or HCO3 is greater than ______
3. When glucose is less than _______
4. when patient can tolerate _________

Answer 5

1. 12
2. 7.3, 15
3. 200
4. oral intake

Question 6

Failure of Na+ to improve after treatment may be an early sign of risk for what?

Answer 6

Cerebral edema

Question 7

In DKA there is total body depletion.

When should you not administer Insulin in the treatment of a DKA patient?

Why?

Answer 7

• If the patient is hyperkalemic, do no administer insulin until K+ is in normal range
• Insulin drives K+ intracellularly (which causes problems)

Question 8

On ECG:

1. What will hypokalemia show?
2. what will hyperkalemia show?

Answer 8

1. hypokalemia = flat T waves, U waves, prolonged PR interval
2. hyperkalemia will cause peaked T waves

Question 9

pic

Answer 9

Rate: Ventricular rate 81

Rhythm: Normal Sinus Rhythm

Axis: Normal Axis

Final ECG Interpretation: U waves consistent with hypokalemia