Difference between revisions of "Diabetic ketoacidosis (peds)"

(IV Fluids)
Line 21: Line 21:
  
 
==General Treatment==
 
==General Treatment==
===[[IV Fluids]]===
+
*Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)
*Bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)
 
*Replace fluid deficit evenly over 48hr w/ NS or 1/2 NS
 
*When BS <250:
 
**Change fluid to D51/2NS @ rate to correct fluid deficit in 48hr; maintain BS 150-250
 
  
===Insulin===
+
===[[IV Fluids|Manage Hydration]]===
**IV Infusion 0.1 units/kg/hr
+
*If K+<5.5
***Cont until HCO3 > 15 and pH>7.3
+
**0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
**Decrease infusion to 0.05 u/kg/hr until 1hr after SC insulin initiated
+
***When BS <300, change to D5/0.45%NS (or NS) +20 KPhos @ 1.5 x maintenance rate (maintain BS 150-250)
 +
 
 +
===Manage Acidosis===
 +
*Insulin drip 0.1 units/kg/hr (max 7 units/hr)
 +
**Do not start if K+ <4.0 (repleate 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===
 
===Potassium===
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**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===
 +
*Cerebral edema (1% of DKA)
 +
**Acute change in mental status
 +
**Signs of herniation
 +
*If present:
 +
**[[Mannitol]] or 3%NS
 +
**Head of bed at 30 degrees
 +
**Stat head CT (non-contrast)
 +
**Consult PICU and neurosurgery
  
 
== Disposion ==
 
== Disposion ==
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==Source==
 
==Source==
Tintinalli
+
<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>
  
 
[[Category:Peds]]
 
[[Category:Peds]]
 
[[Category:Endo]]
 
[[Category:Endo]]

Revision as of 23:51, 9 December 2014

Background

  • DKA + AMS = cerebral edema until proven otherwise

Diagnosis

  • Hyperglycemia (>200)
  • Acidosis
    • pH <=7.30 or bicarb <=15
  • +ketonemia (>1:2 serum dilution)

Workup

  • Point of care glucose (and potassium, if available)
  • CBC
  • Chem 7
  • Magnesium
  • Phosphorus
  • Serum ketones (or beta-OH and acetone)
  • UA
  • Urine pregnancy (if appropriate)
  • VBG
  • Consider studies for possible infectious trigger

General Treatment

  • Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)

Manage Hydration

  • If K+<5.5
    • 0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
      • When BS <300, change to D5/0.45%NS (or NS) +20 KPhos @ 1.5 x maintenance rate (maintain BS 150-250)

Manage Acidosis

  • Insulin drip 0.1 units/kg/hr (max 7 units/hr)
    • Do not start if K+ <4.0 (repleate 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

    • Only consider for:
      • Critically ill (hemodynamic compromise from decr 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

  • Cerebral edema (1% of DKA)
    • Acute change in mental status
    • Signs of herniation
  • If present:
    • Mannitol or 3%NS
    • Head of bed at 30 degrees
    • Stat head CT (non-contrast)
    • Consult PICU and neurosurgery

Disposion

  • Admit all unless
    • Known diabetes
    • pH >7.35 and bicarb >20
    • Known and resolving precipitant for DKA

Complications

See Also

Diabetic Ketoacidosis (DKA)

Source

[1]

  1. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5