PRTP Emergency Diabetic Ketoacidosis A4 Printable edition

Diabetic Ketoacidosis
When to Suspect?
 Vomiting/abdominal pain + RBS >200 mg/dL or urinary acetone + Risk factor for DKA.

How to Confirm?
Any child meets the following picture:
History (≥ 1) Examination (≥ 1) Investigations (≥ 2)
 Weight loss  ↑HR , ↑ RR (Kussmaul breathing)  Ketones in urine ≥2+ / or in
 Polyuria  Breath smells of acetone blood (rarely available) Note
 Abdominal Pain Dehydration  RBS (> 200 mg/dL) Deficit fluids are
 Vomiting/Nausea  Drowsiness /Confusion  Acidaemia (venous pH calculated based on
 Blurry vision <7.3, or bicarbonate <15 dehydration %.
mmol/L) Deficit is usually
 Progressive ↓ consciousness
corrected over 47
 Coma hr after the 1st hr
Serum bicarbonate concentration alone can substitute for vpH to diagnose DKA and management.
classify severity in children with new onset diabetes mellitus and is suggested as an
alternative to reliance on vpH in settings where access to vpH measurement is limited.

Risk factors Goals of

Newly diagnosed Known diabetic therapy
 Younger age  Omission of insulin for various reasons - Correct
 Delayed diagnosis  Limited access to medical services dehydration
- Correct acidosis
 Lower socioeconomic status  Poor metabolic control or previous episodes of DKA
- Reverse ketosis
 Gastroenteritis with persistent vomiting and - Gradually restore
inability to maintain hydration hyperosmolality
 Psychiatric disorders, including eating disorders and bl glucose to
 Peripubertal and adolescent girls normal
 Unrecognized interruption of insulin delivery in - Monitor for
patients using an insulin pump complications
and its treatment
1ST HR MANAGEMENT (ER) - Identify and treat
any precipitating
 ABC/Shock assessment: event.
- 100% oxygen (if cardiopulmonary compromised)
- Weight the patient (the current weight not the previous visit one). If unavailable,
measure the body surface area (using height as discussed before).
- NPO ± Suction of gastric contents by NGT (even in the patient who is not obtunded).
- 2 peripheral IV lines.
- Central lines: unless absolutely necessary, AVOID placing a CVC because of the high
risk of thrombosis, especially in the very young child. If a central catheter has been
inserted, it should be removed as soon as the patient's clinical status permits. low
molecular weight heparin should be considered especially in children >12 years
 Assess and treat dehydration/Shock (see GE & Shock)
- If shock: 20 mL/kg over 20 min up to 3 doses in 1st hr.
- If not shocked: 10 mL/kg over 30-60 min or 15-30 if poor perfusion.
- Don’t give insulin bolus → cerebral edema, shock by rapidly ↓↓ osmotic pressure, and
↑↑ hypokalemia
- Don’t correct low serum bicarbonate at the start of Rx. It will be corrected with the
correction of metabolic status.
- ≥10% dehydration ─ weak or impalpable peripheral pulses, hypotension, or oliguria.
 Assess the level of consciousness: using Glasgow coma scale [GCS]
- In the unconscious or severely obtunded patient without normal airway protective
reflexes → secure the airway and empty the stomach by continuous nasogastric
suction to prevent pulmonary aspiration.
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PRTP Emergency Diabetic Ketoacidosis A4 Printable edition

- Intubation should be avoided if possible; an increase of pCO2 during or following

intubation above the level that the patient had been maintaining may cause CSF pH
to decrease and contribute to worsening of cerebral edema.
 Investigations
- Blood sample: VBG, blood glucose, CBC, CRP, Na, K, Mg, Ca, Cl, Albumin, PO4,
BUN, Lactate, Urea and Creatinine, and culture.
- Urine sample: Ketones, analysis (avoid catheter, unless necessary), and culture.
 Antibiotics to febrile patients after obtaining appropriate cultures of body fluids
 Classify according:
Mild Moderate Severe
Venous Bl gases
- pH < 7.3 < 7.2 < 7.1
- CO2 < 20 < 15 < 10
- HCO3 < 15 < 10 <5
Acetone in urine Trace to +1 +2 +3
Dehydration < 5% 5-10 % > 10%
Oriented, alert Kussmaul breath Kussmaul breath
Clinical
± fatigued ± Sleepy ± Coma
Decision Ward Intermediate ICU PICU

NEXT-HOURS MANAGEMENT
 ABC: as in 1st hour according to need (NPO until resolved acidosis and no nausea).
 Monitoring:
- There should be documentation on a flow chart of:
- Hourly (or more frequently as indicated) vital signs (HR, RR, BP).
- Hourly (or more frequently as indicated) neurological observations:
- Onset of headache after starting Rx - ↑↑ BP
or worsening of headache already - ↓↓ SpO2
present before Rx - Rapidly ↑↑ Na suggesting loss of
- Inappropriate ↓↓ HR urinary free water as (DI).
- Recurrence of vomiting - Amount of administered insulin
- Change in neurological status
- Hourly fluid balance, and RBS.
- Electrolytes and raised labs at baseline after 2 hr then q 4hr.

 Fluid therapy:
- Calculate: [2 x Maintenance + deficit (according to dehydration) – Shock] over 47 hr
- Start using: NS (0.9% NaCl) unless Na monitoring suggests something else.
- If RBS <250: start D5W-1/2 NS instead of NS (May need D10W if rapid drop in RBS).
- If RBS <70: give a bolus of 2 mL/kg of 10% glucose and ↑glucose conc or ↓ insulin.
- To avoid excessive fluid administration in obese patients, fluid calculations should
be based on an approximation of ideal body weight for height.
- For body weights >32 kg, the volumes has to be adjusted so as not to exceed twice
the maintenance rate of fluid administration.
- There should be a concomitant increase in serum Na as the serum glucose decreases
(serum Na should ↑↑ by 0.5 mmol/L for each 18 mg/dL decrease in glucose).
- Na: if >150, or shows +Ve trend (for each 100 mg drop in RBS, Na ↑↑ by 2 mEq) →
shift IVF from 0.9% to 0.45% NaCl.
- Use corrected Na instead of measured Na, as it is affected by glucose.
Corrected Na = [measured Na + {1.6 (gluc-100) /100}]

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PRTP Emergency Diabetic Ketoacidosis A4 Printable edition
 Insulin therapy:
- IV in a separate line, one hour after IVF start.
- Composition: 50 units of rapid insulin + 50 mL NS (1u /mL).
- Don’t compose insulin with 500 mL (too much uncalculated IV fluids).
- Dose: 0.05-0.1 mL/Kg/hr (0.5-1 mL/hr for each 10 kg). Notes
- If the patient shows marked sensitivity to insulin, the insulin dose may be ↓↓ to Never start insulin
(0.03 U/kg/h) provided that metabolic acidosis continues to resolve. until no shock and K
- For mild or moderate DKA in child < 5yr, (0.03 U/kg/h) IV insulin is sufficient. is > 2.5 at least.
- If RBS <250-300: you may ↓↓ insulin rate, or change the IV fluids into (D5W + ½ NS) Never stop insulin
or both according to the response of RBS. until no acidosis.
- If RBS falls very rapidly (>90 mg/dL/h) after initial fluid expansion, consider adding
glucose even before plasma glucose has decreased to 300 mg/dL.
- Insulin has an aldosterone-like effect →↑↑ urinary K excretion, so the time on IV
insulin and dose of insulin should be minimized to avoid severe hypokalemia.
- If continuous IV insulin is not possible and in patients with uncomplicated DKA,
hourly or 2-hourly SC rapid-acting insulin analog (insulin lispro or insulin aspart) is
safe and may be as effective as IV regular insulin infusion, but, ideally, should not
be used in patients whose peripheral circulation is impaired.
- Initial dose SC: 0.3 unit/kg, followed 1 hour later by SC insulin lispro or aspart at
0.1 unit/kg every hour, or 0.15 to 0.20 units/kg every 2 to 3 hours.
 IV KCl: Notes
- Vomiting, Volume depletion (secondary hyperaldosteronism→ urinary K excretion), The major loss of K is
and osmotic diuresis cause potassium loss. Total body depletion of potassium from the intracellular
occurs; however, at presentation serum potassium levels may be normal, increased, pool, because of trans-
or decreased. Renal dysfunction, by enhancing hyperglycemia and reducing cellular shifts caused by
potassium excretion, contributes to hyperkalemia. So replacement therapy is hypertonicity. K is lost
from the body due to
required regardless of the serum K, except in renal failure.
volume depletion,
- Started after the 1st hr (volume expansion). Make sure the child is passing urine.
vomiting and osmotic
- If serum K measurement is not available, ECG may help (T wave changes). diuresis.
- KCL 15% amp 10 mEq/5mL
- Add KCl to the IV fluids according to serum K:
Serum K ≥6 5.5-<6 3.5-5.5 <3.5
KCl added No KCl Follow up 2-4 amp/L 4 amp/L

- K replacement should continue throughout IV fluid therapy.

- The maximum recommended rate of IV KCl replacement is usually 0.5 mmol/kg/h.
If hypokalemia persists despite a maximum rate of potassium replacement, then
the rate of insulin infusion can be reduced and check serum Mg → If low Mg: (call
your senior) add 0.25-0.5 mL/kg Mg to 500 mL of the IVF.
- Profound hypokalemia (<2.5 mmol/L) → necessitates vigorous K replacement while
delaying the start of insulin therapy until serum potassium levels are >2.5 mmol/L
to reduce the risk of cardiopulmonary and neuromuscular compromise.
 Acid-base balance:
- Anion gap = [Na – (HCO3 + Cl)] Normally 12 ± 2
Up to 20-30 in DKA
If > 35 → lactic acidosis.
- Effective osmolarity= [2x plasma Na + (plasma Gluc in mg/18)]. Normally 275-295
If ≥ 310 → risk of brain edema
If ≥ 370 → Multiple-organ failure (MOF).

 TLC: may be ↑ due to stress and dehydration

It may also indicate bacterial infection if Staff/TLC > 0.2.

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PRTP Emergency Diabetic Ketoacidosis A4 Printable edition

What are signs of recovery?

 Labs:
- Normal electrolytes (Na, Cl, K)
- ABG: pH >7.3, HCO3 >15, CO2 ≥16
 Clinical:
- The child is drinking well and able to tolerate food, no dehydration
- IV fluids and insulin can be discontinued.
 Start SC insulin:
- In the newly-diagnosed diabetic 0.4-0.6 U/kg according to local protocol, or
resume usual insulin regimen in known diabetics.
- Discontinue the insulin infusion: 60 min after the first SC injection.

What are signs of treatment failure?

 Blood glucose is uncontrollable
 If biochemical parameters of DKA (venous pH, anion gap) do not improve (in ~4-
6h), reassess the patient, review insulin therapy, and consider other possible
causes of impaired response to insulin; e.g. infection, errors in insulin
preparation or route).
- Call your consultant.

Complications (PICU)
 Cerebral edema
- Onset of headache after beginning Rx or progressively worsening headache.
- Change in neurological status (irritability, confusion, inability to arouse,
incontinence).
- Specific neurological signs (eg, cranial nerve palsies, papilledema).
- Cushing's triad (rising blood pressure, bradycardia, and respiratory depression)
is a late but important sign of increased intracranial pressure.
- Decreased O2 saturation
 Hypokalemia
 Hypomagnesemia
 Hypophosphatemia
 Hyperchloremic acidosis

Potassium ECG
Increased K+

Decreased K+

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PRTP Emergency Diabetic Ketoacidosis A4 Printable edition

DIABETIC KETOACIDOSIS

Diagnosis
C/P, RBS>200 usually, pH<7.3, Acetone in urine (+2)

Time
IVF Bolus
ABC
10-20 mL/kg 0.9% NaCl
0 min Suction, O2, 2 IV lines,
20 mL/kg if shocked, may be repeated
NPO, NGT
3x, until no shock

IVF
(2 Maintenance + Deficit - Bolus) / 47hr
60 min KCl (15% amp)
Give 0.9% NS unless positive Na trend
if (6): add no K
or >150 → change to 0.45% NaCl
if 5.5-6: follow up
If 3.5-5.5: 2-4 amp/L IV insulin
if <3.5: 4 amp/L Insulin 50 units + 50 mL NS → 0.05-0.1
mL/kg/hr

If persistent
low K If RBS <250-300

Check serum Mg →
if low, add 0.25- IVF: Add D5% to the IVF
0.5mL/kg to 500 mL
NS within IVF
Insulin: ↓ rate (not < 0.03-0.05)
If not tray ↓ insulin rate

60 min SC insulin: 60 min before

before discontinuing IV insulin

Recovery: C/P improvement, normal RBS, no Acidosis, normal

~48 hr
electrolytes.

Gradually ↓ IV KCl Gradually ↓ IVF/IV insulin until stopped

until changed to PO and started PO feeding and water