Difference between revisions of "Diabetic ketoacidosis (peds)"

(Manage AcidosisCooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5)
 
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{{Peds top}} [[diabetic ketoacidosis]]
 
==Background==
 
==Background==
 
*DKA + altered mental status = cerebral edema until proven otherwise
 
*DKA + altered mental status = cerebral edema until proven otherwise
  
 
==Clinical Features==
 
==Clinical Features==
===History===
 
 
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
 
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
*Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain
+
*Signs/symptoms may include:
*Perform a thorough neurologic exam (cerebral edema increases mortality significantly, especially in children)
+
**[[Tachypnea]], Kussmaul's breathing
*Assess for possible inciting cause (esp for ongoing infection; see Differential Diagnosis section)
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**[[Polyuria]], polydipsia, polyphagia, [[failure to thrive (peds)|poor weight gain]]/weight loss
 
+
**Signs of [[dehydration (peds)|dehydration]]
===Physical===
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**[[Abdominal pain]], [[nausea and vomiting (peds)|nausea/vomiting]]
*Drowsiness
+
**[[Altered mental status (peds)|Altered mental status]], drowsiness, lethargy
*Tachypnea (Kussmaul's breathing)
+
***Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
*Signs of dehydration
+
*+/- signs/symptoms of precipitating trigger for decompensation (e.g. [[pneumonia]], [[cellulitis]])
*Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
+
*Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA
*There may be signs from underlying cause (eg pneumonia)
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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===Workup===
 
===Workup===
 
*Point of care glucose (and potassium, if available)
 
*Point of care glucose (and potassium, if available)
*CBC
+
*[[VBG]]
 
*Chem 7
 
*Chem 7
 
*Magnesium
 
*Magnesium
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*Serum ketones (or beta-OH and acetone)
 
*Serum ketones (or beta-OH and acetone)
 
*[[Urinalysis]]
 
*[[Urinalysis]]
 +
*CBC
 
*Urine pregnancy (if appropriate)
 
*Urine pregnancy (if appropriate)
*VBG
+
*Consider infectious workup to identify trigger
*Consider studies for possible infectious trigger
 
  
===Evaluation===
+
===Diagnosis===
*Hyperglycemia (>200)
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*[[Hyperglycemia]] (>200)
*Acidosis
+
*[[Acidosis]]
 
**pH <=7.30 or bicarb <=15
 
**pH <=7.30 or bicarb <=15
 
*+ketonemia (>1:2 serum dilution)
 
*+ketonemia (>1:2 serum dilution)
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**0.45% NS (or NS) + 20 KPhosat 1.5 x [[IVF maintenance|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 at 1.5 x [[IVF maintenance|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  
+
*[[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
+
**Continue until HCO3 >15 and pH >7.3, then transition to 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
  
 
===Potassium===
 
===Potassium===
*if < 2.5, hold insulin and give 1 meq/kg KCL in IV over 1hr
+
*if < 2.5, hold insulin and give 1 meq/kg [[potassium KCL in IV over 1hr
 
**No insulin until K > 2.5
 
**No insulin until K > 2.5
 
*if > 2.5 but < 3.5 give 40-60 meq/L in IV until K > 3.5
 
*if > 2.5 but < 3.5 give 40-60 meq/L in IV until K > 3.5
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===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 in DKA|Cerebral edema]] (1% of DKA)
 
*[[Cerebral edema in DKA|Cerebral edema]] (1% of DKA)
**Acute change in mental status
+
**Acute [[altered mental status (peds)|change in mental status]]
**Signs of herniation
+
**Signs of [[herniation Syndromes|herniation]]
*If present see [[Cerebral Edema in DKA]]
+
*If present, see [[Cerebral Edema in DKA]]
  
 
==Disposition==
 
==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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*[[Diabetes mellitus (main)]]
 
*[[Diabetes mellitus (main)]]
 
*[[Diabetic ketoacidosis]] (main)
 
*[[Diabetic ketoacidosis]] (main)
*Evidence Review Sodium Bicarbonate in DKA]]
+
*[[EBQ:Sodium Bicarbonate use in DKA]]
 +
*[[Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis]]
  
 
==External Links==
 
==External Links==

Latest revision as of 22:58, 28 November 2019

This page is for pediatric patients. For adult patients, see: diabetic ketoacidosis

Background

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

Clinical Features

  • May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
  • Signs/symptoms may include:
  • +/- signs/symptoms of precipitating trigger for decompensation (e.g. pneumonia, cellulitis)
  • Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA

Differential Diagnosis

Hyperglycemia

Evaluation

Workup

  • Point of care glucose (and potassium, if available)
  • VBG
  • Chem 7
  • Magnesium
  • Phosphorus
  • Serum ketones (or beta-OH and acetone)
  • Urinalysis
  • CBC
  • Urine pregnancy (if appropriate)
  • Consider infectious workup to identify 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)
    • Continue until HCO3 >15 and pH >7.3, then transition to 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 [[potassium 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