Diabetic ketoacidosis (peds): Difference between revisions

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==Treatment==
{{Peds top}} [[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:
**[[Tachypnea]], Kussmaul's breathing
**[[Polyuria]], polydipsia, polyphagia, [[failure to thrive (peds)|poor weight gain]]/weight loss
**Signs of [[dehydration (peds)|dehydration]]
**[[Abdominal pain]], [[nausea and vomiting (peds)|nausea/vomiting]]
**[[Altered mental status (peds)|Altered mental status]], drowsiness, lethargy
***Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
*+/- 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


1) IV Fluids
==Differential Diagnosis==
{{Hyperglycemia DDX}}


    Bolus 20ml/kg NS prn unstable VS
==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


    NS@10ml/hr/kg for stable VS
===Diagnosis===
*[[Hyperglycemia]] (>200)
*[[Acidosis]]
**pH <=7.30 or bicarb <=15
*+ketonemia (>1:2 serum dilution)


    Replace fluid deficit evenly over
==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>


            48hrs w/NS or ½NS
===[[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
**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)
*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>


    When BS < 250, go to #5 below
===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
**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


2) Insulin
===[[Bicarbonate]]<ref>[[EBQ:Sodium Bicarbonate use in DKA]]</ref>===
{{EBQ Sodium Bicarbonate use in DKA conclusion}}
*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


    IV Infusion 0.1 units/kg/hr
===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)
**Acute [[altered mental status (peds)|change in mental status]]
**Signs of [[herniation Syndromes|herniation]]
*If present, see [[Cerebral Edema in DKA]]


    Cont until HCO3>p15 and pH>7.3
==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


    Decrease infusion to 0.05 u/kg/hr
==Complications==
*[[Cerebral Edema in DKA]]


            until SC insulin initiated
==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==
*[http://pemplaybook.org/podcast/vomiting-in-the-young-child-nothing-or-nightmare/ Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare]


3) Potassium
==References==
<references/>


      if < 2.5, hold insulin and give
[[Category:Pediatrics]]
 
[[Category:Endocrinology]]
            1 meq/kg KCL in IV over 1hr
 
            No insulin until K > 2.5
 
      if > 2.5 but < 3.5, then give
 
            40-60 meq/L in IV until K > 3.5
 
      if > 3.5 but < 5.5, then give
 
            30-40 meq/L in IV for K=3.5 - 5
 
      if >  5.5, then
 
            check K q1hr
 
 
4) Bicarbonate
 
      if pH < 7.0 after 1hr fluids, then
 
      give 2 meq/kg NaHCO3 in NS x1hr
 
      (don't exceed 155 meq/L Na)
 
 
5) When BS < 250:
 
    Change fluid to D5½NS @ rate to
 
            correct fluid deficit in 48hrs
 
            and maintain BS 150-250
 
            (may require D10 w/lytes)
 
    Check chem7 q2hrs until gap closes
 
 
==Source==
 
 
Adapted from Pani
 
 
 
 
[[Category:Peds]]

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
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