Diabetic ketoacidosis (peds): Difference between revisions

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''This page is for <u>pediatric</u> patients; for adult patients see [[diabetic ketoacidosis]]''
==Background==
==Background==
*DKA + AMS = cerebral edema until proven otherwise
*DKA + altered mental status = cerebral edema until proven otherwise


==Diagnosis==
==Clinical Features==
*Hyperglycemia (>200)
===History===
*Acidosis
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
**pH <=7.30 or bicarb <=15
*Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain
*+ketonemia (>1:2 serum dilution)
*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 DDX}}


==Workup==
==Evaluation==
===Workup===
*Point of care glucose (and potassium, if available)
*Point of care glucose (and potassium, if available)
*CBC
*CBC
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*Phosphorus
*Phosphorus
*Serum ketones (or beta-OH and acetone)
*Serum ketones (or beta-OH and acetone)
*UA
*[[Urinalysis]]
*Urine pregnancy (if appropriate)
*Urine pregnancy (if appropriate)
*VBG
*VBG
*Consider studies for possible infectious trigger
*Consider studies for possible infectious trigger
===Diagnosis===
*[[Hyperglycemia]] (>200)
*[[Acidosis]]
**pH <=7.30 or bicarb <=15
*+ketonemia (>1:2 serum dilution)


==General Treatment==
==General Treatment==
*Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>
*Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>


===[[IV Fluids|Manage Hydration]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
===[[IV Fluids|Manage Hydration]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
*If K+<5.5
*If K+<5.5
**0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
**0.45% NS (or NS) + 20 KPhosat 1.5 x [[IVF maintenance|maintenance rate]]
***When BS <300, change to D5/0.45%NS (or NS) +20 KPhos @ 1.5 x maintenance rate (maintain BS 150-250)
***When BS <300, change to D5/0.45%NS (or NS) +20 KPhos at 1.5 x [[IVF maintenance|maintenance rate]] (maintain BS 150-250)
*In a retrospective study, lactated ringers when compared with normal saline was associated with lower total cost and rate of development of cerebral edema. <ref>Bergmann, K. R., Jennifer Abuzzahab, M., Nowak, J., Arms, J., Cutler, G., Christensen, E., … Kharbanda, A. (2018). Resuscitation With Ringerʼs Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatric Emergency Care, 1.</ref>


===Manage Acidosis<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
===Manage Acidosis<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
*Insulin drip 0.1 units/kg/hr (max 7 units/hr)
*Insulin drip 0.1 units/kg/hr  
**Do not start if K+ <4.0 (repleate K+ first)
**Do not start if K+ <4.0 (replete K+ first)
**Cont until HCO3 >15 and pH >7.3, then initiate SC insulin
**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
***Decrease infusion to 0.05 units/kg/hr until 1hr after SC insulin initiated
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*if >  5.5, then check K q1hr
*if >  5.5, then check K q1hr


===Bicarbonate===
===[[Bicarbonate]]<ref>[[EBQ:Sodium Bicarbonate use in DKA]]</ref>===
{{EBQ Sodium Bicarbonate use in DKA conclusion}}
*Only consider for:
*Only consider for:
**Critically ill (hemodynamic compromise from decr contractility) AND
**Critically ill (hemodynamic compromise from decreased contractility) AND
**pH <7.0
**pH <7.0
*0.5-2 mEq/kg over 1-2hr
*0.5-2 mEq/kg over 1-2hr
**Correction should never exceed pH > 7.1 or bicarb >10
**Correction should never exceed pH > 7.1 or bicarb >10


===Monitor for Complications===<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>
===Monitor for Complications<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
*Cerebral edema (1% of DKA)
*[[Cerebral edema in DKA|Cerebral edema]] (1% of DKA)
**Acute change in mental status
**Acute change in mental status
**Signs of herniation
**Signs of herniation
*If present:
*If present see [[Cerebral Edema in DKA]]
**[[Mannitol]] or 3%NS
**Head of bed at 30 degrees
**Stat head CT (non-contrast)
**Consult PICU and neurosurgery


== Disposion ==
==Disposition==
*Admit all unless
*Admit all (usually to PICU, if on insulin drip) unless
**Known diabetes
**Known diabetes
**pH >7.35 and bicarb >20
**pH >7.35 and bicarb >20
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==See Also==
==See Also==
[[Diabetic Ketoacidosis (DKA)]]
*[[Diabetes mellitus (main)]]
*[[Diabetic ketoacidosis]] (main)
*[[EBQ:Sodium Bicarbonate use in DKA]]
*[[Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis]]
 
==External Links==
*[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]


==Source==
==References==
<references/>
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Endo]]
[[Category:Endocrinology]]

Revision as of 17:21, 17 October 2018

This page is for pediatric patients; for adult patients see diabetic ketoacidosis

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
  • In a retrospective study, lactated ringers when compared with normal saline was associated with lower total cost and rate of development of cerebral edema. [3]

Manage Acidosis[4]

  • Insulin drip 0.1 units/kg/hr
    • Do not start if K+ <4.0 (replete 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[5]

  • 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[6]

Disposition

  • Admit all (usually to PICU, if on insulin drip) 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. Bergmann, K. R., Jennifer Abuzzahab, M., Nowak, J., Arms, J., Cutler, G., Christensen, E., … Kharbanda, A. (2018). Resuscitation With Ringerʼs Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatric Emergency Care, 1.
  4. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  5. EBQ:Sodium Bicarbonate use in DKA
  6. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5