Diabetic ketoacidosis (peds): Difference between revisions
 
(44 intermediate revisions by 9 users not shown)
Line 1: Line 1:
{{Peds top}} [[diabetic ketoacidosis]]
==Background==
==Background==
*DKA + AMS = cerebral edema until proven otherwise
*DKA + altered mental status = cerebral edema until proven otherwise


==Diagnosis==
==Clinical Features==
*Hyperglycemia (>200)
[[File:PMC3937174 2251-6581-12-47-1.png|thumb|Frequency of signs and symptoms among 37 pediatric patients with diabetic ketoacidosis in Nigeria.]]
*Acidosis
*May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
**pH <=7.30 or bicarb <=15
*Signs/symptoms may include:
*+ketonemia (>1:2 serum dilution)
**[[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
 
==Differential Diagnosis==
{{Hyperglycemia DDX}}


==Workup==
==Evaluation==
===Workup===
*Point of care glucose (and potassium, if available)
*Point of care glucose (and potassium, if available)
*CBC
*[[VBG]]
*Chem 7
*Chem 7
*Magnesium
*Magnesium
*Phosphorus
*Phosphorus
*Serum ketones (or beta-OH and acetone)
*Serum ketones (or beta-OH and acetone)
*UA
*[[Urinalysis]]
*CBC
*Urine pregnancy (if appropriate)
*Urine pregnancy (if appropriate)
*VBG
*Consider infectious workup to identify trigger
*Consider studies for possible infectious trigger
 
===Diagnosis===
*[[Hyperglycemia]] (>200)
*[[Acidosis]]
**pH <=7.30 or bicarb <=15
*+ketonemia (>1:2 serum dilution)


==General Treatment==
==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>
*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>


===[[IV Fluids|Manage Hydration]]<ref>Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5</ref>===
===[[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
*If K+<5.5
**0.45% NS (or NS) + 20 KPhos@ 1.5 x maintenance rate
**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 @ 1.5 x maintenance rate (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)
*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 (max 7 units/hr)
*[[Insulin]] drip 0.1 units/kg/hr  
**Do not start if K+ <4.0 (repleate K+ first)
**Do not start if K+ <4.0 (replete K+ first)
**Cont until HCO3 >15 and pH >7.3, then initiate SC insulin
**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
Line 42: Line 61:
*if >  5.5, then check K q1hr
*if >  5.5, then check K q1hr


===Bicarbonate===
===[[Bicarbonate]]<ref>[[EBQ:Sodium Bicarbonate use in DKA]]</ref>===
**Only consider for:
{{EBQ Sodium Bicarbonate use in DKA conclusion}}
***Critically ill (hemodynamic compromise from decr contractility) AND
*Only consider for:
***pH <7.0
**Critically ill (hemodynamic compromise from decreased contractility) AND
**0.5-2 mEq/kg over 1-2hr
**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


===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 (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:
*If present, see [[Cerebral Edema in DKA]]
**[[Mannitol]] or 3%NS
**Head of bed at 30 degrees
**Stat head CT (non-contrast)
**Consult PICU and neurosurgery


== Disposion ==
==Disposition==
*Admit all unless
*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
Line 69: Line 85:


==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==
<references/>
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Endo]]
[[Category:Endocrinology]]

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

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
  • 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
Retrieved from "https://www.wikem.org/w/index.php?title=Diabetic_ketoacidosis_(peds)&oldid=372421"