Difference between revisions of "Diabetic ketoacidosis (peds)"

 
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{{Peds top}} [[diabetic ketoacidosis]]
 
==Background==
 
==Background==
 +
*DKA + altered mental status = cerebral edema until proven otherwise
  
==Diagnosis==
+
==Clinical Features==
*Hyperglycemia (>200)
+
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
*Acidosis
+
*Signs/symptoms may include:
**pH <7.25-7.30 or bicarb <15
+
**[[Tachypnea]], Kussmaul's breathing
*+ ketonemia (>1:2 serum dilution)
+
**[[Polyuria]], polydipsia, polyphagia, [[failure to thrive (peds)|poor weight gain]]/weight loss
*DKA + AMS = cerebral edema until proven otherwise
+
**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
 +
 
 +
==Differential Diagnosis==
 +
{{Hyperglycemia DDX}}
 +
 
 +
==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===
 +
*[[Hyperglycemia]] (>200)
 +
*[[Acidosis]]
 +
**pH <=7.30 or bicarb <=15
 +
*+ketonemia (>1:2 serum dilution)
  
 
==General Treatment==
 
==General Treatment==
===[[IV Fluids]]===
+
*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>
**NS @ 10ml/hr/kg for stable VS
+
 
**Bolus 20ml/kg NS only for unstable VS
+
===[[IV Fluids|Manage Hydration]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
**Replace fluid deficit evenly over 48hr w/ NS or 1/2 NS
+
*If K+<5.5
**When BS <250:
+
**0.45% NS (or NS) + 20 KPhosat 1.5 x [[IVF maintenance|maintenance rate]]
***Change fluid to D51/2NS @ rate to correct fluid deficit in 48hr; 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)
===Insulin===
+
*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>
**IV Infusion 0.1 units/kg/hr
+
 
***Cont until HCO3 > 15 and pH>7.3
+
===Manage [[Acidosis]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
**Decrease infusion to 0.05 u/kg/hr until 1hr after SC insulin initiated
+
*[[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===
 
===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
**if > 3.5 but < 5.5 give 30-40 meq/L in IV for K=3.5 - 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
+
*if >  5.5, then check K q1hr
===Bicarbonate===
+
 
**Only consider for:
+
===[[Bicarbonate]]<ref>[[EBQ:Sodium Bicarbonate use in DKA]]</ref>===
***Critically ill (hemodynamic compromise from decr contractility) AND
+
{{EBQ Sodium Bicarbonate use in DKA conclusion}}
***pH <7.0
+
*Only consider for:
**0.5-2 mEq/kg over 1-2hr
+
**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
 
**Correction should never exceed pH > 7.1 or bicarb >10
  
== Disposion ==
+
===Monitor for Complications<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
*Admit all unless
+
*[[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]]
 +
 
 +
==Disposition==
 +
*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==
Tintinalli
+
<references/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
[[Category:Endo]]
+
[[Category:Endocrinology]]

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