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 + | *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 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) | ||
* | *[[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 | **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 | ***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 | *Insulin drip 0.1 units/kg/hr | ||
**Do not start if K+ <4.0 ( | **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 | **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 | ===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]] | ||
== | ==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 | *[[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] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pediatrics]] | ||
[[Category: | [[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
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
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
- Hyperglycemia (>200)
- Acidosis
- pH <=7.30 or bicarb <=15
- +ketonemia (>1:2 serum dilution)
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
- 0.45% NS (or NS) + 20 KPhosat 1.5 x maintenance rate
- When BS <300, change to D5/0.45%NS (or NS) +20 KPhos at 1.5 x maintenance rate (maintain BS 150-250)
- 0.45% NS (or NS) + 20 KPhosat 1.5 x maintenance rate
- 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]
- Cerebral edema (1% of DKA)
- Acute change in mental status
- Signs of herniation
- If present see Cerebral Edema in DKA
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
- Diabetes mellitus (main)
- Diabetic ketoacidosis (main)
- EBQ:Sodium Bicarbonate use in DKA
- Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis
External Links
References
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
- ↑ 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.
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
- ↑ EBQ:Sodium Bicarbonate use in DKA
- ↑ Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5