Diabetic ketoacidosis (peds)

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Background

  • DKA + altered mental status = cerebral edema until proven otherwise

Clinical Features

History

  • May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
  • Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain
  • Perform a thorough neurologic exam (cerebral edema increases mortality significantly, especially in children)
  • Assess for possible inciting cause (esp for ongoing infection; see Differential Diagnosis section)
  • Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA

Physical

  • Drowsiness
  • Tachypnea (Kussmaul's breathing)
  • Signs of dehydration
  • Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
  • There may be signs from underlying cause (eg pneumonia)

Differential Diagnosis

Hyperglycemia

Evaluation

Workup

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

Diagnosis

General Treatment

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

Manage Hydration[2]

  • If K+<5.5

Manage Acidosis[3]

  • Insulin drip 0.1 units/kg/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[4]

  • No evidence supports the use of sodium bicarb in DKA, with a pH >6.9
  • However, no studies have been performed for patients with pH <6.9 and the most recent ADA guidelines recommend it for patients with pH <7.1
  • Only consider for:
    • Critically ill (hemodynamic compromise from decreased 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[5]

Disposition

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

Complications

See Also

External Links

References

  1. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  2. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  3. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  4. EBQ:Sodium Bicarbonate use in DKA
  5. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5