Diabetic ketoacidosis (peds)

Revision as of 04:21, 10 December 2014 by Rossdonaldson1 (talk | contribs) (Bicarbonate)

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)[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)

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]

  • 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:
    • 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. 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. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5
  4. EBQ:Sodium Bicarbonate use in DKA
  5. Cooke & Plotnick. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008 Dec;29(12):431-5