Diabetic ketoacidosis (peds)

Background

• DKA + AMS = cerebral edema until proven otherwise

Diagnosis

• Hyperglycemia (>200)
• Acidosis
  • pH <=7.30 or bicarb <=15
• +ketonemia (>1:2 serum dilution)

Workup

• Point of care glucose (and potassium, if available)
• CBC
• Chem 7
• Magnesium
• Phosphorus
• Serum ketones (or beta-OH and acetone)
• UA
• Urine pregnancy (if appropriate)
• VBG
• Consider studies for possible infectious trigger

General Treatment

• Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)

Manage Hydration

• If K+<5.5
  • 0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
    • When BS <300, change to D5/0.45%NS (or NS) +20 KPhos @ 1.5 x maintenance rate (maintain BS 150-250)

Manage Acidosis

• Insulin drip 0.1 units/kg/hr (max 7 units/hr)
  • Do not start if K+ <4.0 (repleate K+ first)
  • Cont until HCO3 >15 and pH >7.3, then initiate SC insulin
    • Decrease infusion to 0.05 units/kg/hr until 1hr after SC insulin initiated

Potassium

• • if < 2.5, hold insulin and give 1 meq/kg KCL in IV over 1hr
    • No insulin until K > 2.5
  • if > 2.5 but < 3.5 give 40-60 meq/L in IV until K > 3.5
  • if > 3.5 but < 5.5 give 30-40 meq/L in IV for K=3.5 - 5
  • if > 5.5, then check K q1hr

Bicarbonate

• • Only consider for:
    • Critically ill (hemodynamic compromise from decr contractility) AND
    • pH <7.0
  • 0.5-2 mEq/kg over 1-2hr
  • Correction should never exceed pH > 7.1 or bicarb >10

Monitor for Complications

• Cerebral edema (1% of DKA)
  • Acute change in mental status
  • Signs of herniation
• If present:
  • Mannitol or 3%NS
  • Head of bed at 30 degrees
  • Stat head CT (non-contrast)
  • Consult PICU and neurosurgery

Disposion

• Admit all unless
  • Known diabetes
  • pH >7.35 and bicarb >20
  • Known and resolving precipitant for DKA

Complications

• Cerebral Edema in DKA

See Also

Diabetic Ketoacidosis (DKA)