Diabetic ketoacidosis (peds): Difference between revisions
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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== | ||
[[File:PMC3937174 2251-6581-12-47-1.png|thumb|Frequency of signs and symptoms among 37 pediatric patients with diabetic ketoacidosis in Nigeria.]] | |||
*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 | ||
* | *Signs/symptoms may include: | ||
*Perform a thorough neurologic exam | **[[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 | |||
**Breath fruity odor (acetone) | |||
***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 | *Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA | ||
==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) | ||
* | *[[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) | ||
*Consider infectious workup to identify trigger | |||
*Consider | |||
===Diagnosis=== | ===Diagnosis=== | ||
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*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> | *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) | ||
** | **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== |
Latest revision as of 00:37, 1 February 2024
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:
- Tachypnea, Kussmaul's breathing
- Polyuria, polydipsia, polyphagia, poor weight gain/weight loss
- Signs of dehydration
- Abdominal pain, nausea/vomiting
- Altered mental status, drowsiness, lethargy
- Breath fruity odor (acetone)
- 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
- 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)
- 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
- 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)
- 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]
- 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