Diabetic ketoacidosis (peds): Difference between revisions
Line 88: | Line 88: | ||
==External Links== | ==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] | ||
==References== | ==References== |
Revision as of 07:20, 14 December 2015
Background
- DKA + AMS = cerebral edema until proven otherwise
Clinical Features
History
- May be the initial presenting of an unrecognized T1DM patient
- Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain
- Perform a thorough neurologic exam (cerebral edema increases mortality significantly, especially in children)
- Assess for possible inciting cause (esp for ongoing infection; see Differential Diagnosis section)
Physical
- Drowsiness
- Tachypnea (Kussmaul's breathing)
- Signs of dehydration
- Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
- There may be signs from underlying cause (eg pneumonia)
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
Diagnosis
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
Evaluation
- 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 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)
- 0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
Manage Acidosis[3]
- 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[4]
- 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 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[5]
- Cerebral edema (1% of DKA)
- Acute change in mental status
- Signs of herniation
- If present see Cerebral Edema in DKA
Disposition
- Admit all unless
- Known diabetes
- pH >7.35 and bicarb >20
- Known and resolving precipitant for DKA
Complications
See Also
- Diabetes mellitus (main)
- Diabetic ketoacidosis (main)
- Evidence Review Sodium Bicarbonate in DKA]]
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
- ↑ 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