Diabetic ketoacidosis (peds)
Background
- (pH <7.25-7.30 or bicarb <15) + hyperglycemia (>300) + ketonemia (>1:2 serum dilution)
- DKA + AMS = cerebral edema until proven otherwise
Cerebral Edema
Risk Factors
- Age <5yo
- Rare in >20yo
- Severe hyperosmolality
- Failure of Na to rise w/ therapy
- Severe acidosis
- Overaggressive fluid resus is NOT a risk factor
Diagnosis
- Begins 6-12hr after onset of therapy
- Many appear to be improving from their DKA before deteriorating from cerebral edema
- Premonitory symptoms:
- HA, declining mental status, sz, respiratory arrest
Treatment
- Mannitol 0.5-1gm/kg IV bolus OR 3% saline 10mL/kg over 30min
- Fluid restriction
Treatment
- IV Fluids
- NS @ 10ml/hr/kg for stable VS
- Bolus 20ml/kg NS only for unstable VS
- 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 Infusion 0.1 units/kg/hr
- Cont until HCO3 > 15 and pH>7.3
- Decrease infusion to 0.05 u/kg/hr until 1hr after SC insulin initiated
- IV Infusion 0.1 units/kg/hr
- 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
- if < 2.5, hold insulin and give 1 meq/kg KCL in IV over 1hr
- 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
- Only consider for:
Disposion
- Admit all except can consider dischage if:
- Known diabetes
- pH > 7.35 and bicarb > 20
- Known and resolving precipitant for DKA
Source
Tintinalli