Management of DKA in pediatrics

Afework. A (MD,MPH)
Summary of pathophysiology

• Glycogenolysis+gluconeogenesis+ peripheral glucose utilization

hyperglycemia

• Hyperglycemia osmotic diuresis loss of fluid & electrolytes dehydration &

RAAS( K+ loss)

• Catabolic processes loss of intracellular Na+, K+, & Phosphate

• FA release from peripheral tissues metabolism by liver metabolic acidosis

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Cont.

• Treat:
– Hyperglycemia
– Acidosis
– Fluid disturbance
– Electrolyte disturbance
– Precipitating cause

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 Summary of signs and symptoms

Symptoms Signs
 Exacerbation of the ‘poly-  Dehydration
symptoms’  Hypotension
 Abdominal pain and distention  Kussmaul's respiration
 Anorexia, nausea and  Acetone breath
vomiting  Abdominal tenderness and
 Difficult breathing distention
 Stupor, coma
 Leg cramps
 Increased leukocyte count
with left shift4
Diagnosis of DKA
Biochemical criteria

• Hyperglycemia (blood glucose >11 mmol/L [≈200 mg/dL])

• Venous pH <7.3 or bicarbonate <15 mmol/L
• Ketonemia and ketonuria

Source: ISPAD Clinical Practice Consensus Guidelines 2009 Compendium

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DKA severity

Normal Mild Moderate Severe

CO2 meq/l 20-28 16-20 10-15 <10
(venous)
PH(venous) 7.35-7.45 7.25-7.35 7.15-7.25 <7.15
Clinical No change Alert but Kussmual Comatose,
fatigued, no breathing, severe
dehydration sleepy, some dehydration
to severe
dehydartion

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Steps in managing DKA

1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Definitive management of DKA
7. Discharge and follow-up

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Steps in management
General resuscitation

• Airway
– Position the patient and secure the airway
• Head-tilt/chin lift or jaw thrust
• Oral or nasal airway

• Breathing
– Give 100% oxygen
– Ventilate the patient if he/she:
• is not breathing
• has difficulty of breathing
• cannot maintain saturation with low flow systems
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Steps in management
General resuscitation cont.

• Circulation-----look for signs of shock and dehydration

– Not in shock NS/10 ml/kg over 1 hour/may be repeated if necessary
– In shock NS/20 ml/kg bolus infused as quickly as possible through a large bore
cannula/repeat if necessary/careful reassessment after each bolus

• Disability
– Assess conscious status and pupillary reaction
– If comatose, give coma care
• Intubation, NG tube, urinary catheter, position, neuro-sign chart

• Exposure
– Warm the patient(if cold)
– Give antipyretic(if febrile) Your Logo
Steps in managing DKA

1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Definitive management of DKA
7. Discharge and follow-up

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Steps in management
Definitive management of DKA

1. Do baseline investigations
2. Expand intravascular volume
3. Insulin therapy
4. Potassium replacement therapy
5. Monitoring
6. Treat complications
7. Identify and treat precipitating causes
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Definitive management of DKA
Baseline investigations

• Plasma glucose
• Electrolytes (?including bicarbonate or total CO 2)
• Urinalysis (for ketones)
• CBC
• RFT
• Baseline ECG
– For baseline evaluation of K+ status If laboratory measurement of serum K+ is delayed
• Specimens for culture (blood, urine, throat)
– If there is evidence of infection
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Definitive management of DKA
First hour

• 10-20 ml/kg IV bolus 0.9% NaCl or RL

– May be repeated…..NPO…...Monitor I/O

• Start insulin drip??

NB: hypokalemia on time of evaluation start K+ replacement before

starting insulin therapy
– A concentration of 20 mmol/l should be used
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Definitive management of DKA
2nd hr until DKA resolution

• Continue the IV fluid with 0.9% NaCl Iv rate = 85ml/kg + 2(maintenance) – bolus
47hrs
• Start insulin drip
If IV administration of insulin is not possible, use
– 0.05 to 0.1U/kg/hr continuous
SC insulin 0.5 U/kg every 6 hours
– 0.5 U/kg every 4-6 hrs intermittent
1st dose: half IM/half IV
• Give K+(K+phos, KCL, K+acetate, or combination)……40mEq/L
– [K+] = 3 to 4.5 mmol 40 mEq/L of K+
• Max. recommended rate of IV K+
– [K+] = 4.6 to 5 mmol 20 mEq/L of K+
replacement is usually 0.5 mmol/kg/hr
– [K+] > 5 mmol K+ should be withheld in the initial fluids • K+ replacement should continue
– [K+] < 3 mmol K+ of 60 mEq/L or greater may be necessary throughout IV fluid therapy

• 5% dextrose if blood sugar < 250 mg/dL

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• Change fluid to 5% DW in ½ NS( half NS and half DW ) or use DNS
Recall
Definitive management of DKA

1. Do baseline investigations
2. Expand intravascular volume
3. Insulin therapy
4. Potassium replacement therapy
5. Monitoring
6. Treat complications(hypokalemia, hypoglycemia, cerebral
edema)
7. Identify and treat precipitating causes
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Definitive management of DKA
Monitoring

• Clinical
– Vital signs Hourly or more
– Input/output frequently as
– Neurologic signs needed

– ECG

• Laboratorial
– Blood glucose(Q 1hr)
 Every 1-2 hrs for severe DKA
– Serum electrolyte
– PH(if available)  Every 3-4 hrs for mild to moderate DKA

– RFT and ?urine ketones Your Logo

Definitive management of DKA
Treat complications

• Hypokalemia
– Manifestations
• ECG changes
– Flattening of T waves and prolongation of the QRS complex
• Ileus
• Skeletal muscle weakness

– Treatment
• The IV K+ can be increased to 80 mEq/L
• An oral supplement can be given if there is no emesis
• Rarely, the IV insulin must be temporarily stopped or reduced
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Definitive management of DKA
Treat complications cont.

• Hypoglycemia
– Manifestations
• Neuroglycopenic symptoms
– Headache, visual Sxs, confusion, irritability, seizures
• Sympathetic response symptoms
– Tremors, diaphoresis, anxiety, tachycardia

– Treatment
• Switch fluid to DW
• Decrease insulin dose
– If blood glucose levels go below 150 mg/dL despite the addition of glucose to the infusion
– 0.02-0.05 U/kg/hr is usually sufficient to stop peripheral release of fatty acids
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Definitive management of DKA
Treat complications cont.

• Cerebral edema
– Typically occurs 6-12 hrs after therapy is begun
– Manifestations
• Signs and symptoms of ICP
– Headache, ALOC, vomiting, seizure, motor deficit, posturing
– Pupillary changes, papilledema, Cushing's triad

– Treatment
• Reduce the rate of fluid administration by one-third
• Elevate the head of the bed
• Mannitol( 1gm/Kg IV over 20 minutes and repeat if there is no initial response in 30 minutes to 2 hrs)
• Intubation(?hyperventilation)
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Definitive management of DKA
Oral intake with SC insulin

• Criteria
– Total CO2 >15 mEq/L
– PH >7.30
– Na+ between 135 and 145 mEq/L
– No emesis

• To prevent rebound hyperglycemia, the first SC injection should be given 1–2

hrs before stopping the insulin infusion(if the patient was being treated with
IV infusion therapy)
– To allow sufficient time for the insulin to be absorbed
• After transitioning to SC insulin, frequent blood glucose monitoring is required
– To avoid marked hyperglycemia and hypoglycemia
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Recall
Definitive management of DKA

1. Do baseline investigations
2. Expand intravascular volume
3. Insulin therapy
4. Potassium replacement therapy
5. Monitoring
6. Treat complications(hypokalemia, hypoglycemia, cerebral
edema)
7. Identify and treat precipitating causes
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Definitive management of DKA
Identify and treat precipitating causes

• Infection
– Treatment
• Examine the ears, throat, chest, urine, stool, blood and other sites of infection
• Give appropriate antibiotics
• Physical stress
– Trauma, surgery, burn
• Treat accordingly
• Emotional stress
– Puberty, family crises, exam at school
• Psychiatric evaluation and support
• Insulin dose omission
– Deliberate or lack of education
• Provide education Your Logo
Recall
Steps in managing DKA

1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Definitive management of DKA
7. Discharge and follow-up

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Diascharge and follow up

• Children with milder DKA recover in 10-20 hrs whereas those with moderate to severe DKA
require 30-36 hrs

• When to discharge?
– DKA is well controlled
– Precipitating factors are treated
– Patient is able to take SC insulin

• How to discharge?
– With SC insulin
– And basic education(about insulin injection, blood sugar control, meal planning, exercise, about
symptoms of hypo/hyperglycemia, and impact of poor control of DM)
• Followup
– At the endocrinology clinic Your Logo
Management of DKA in non-hospital settings

• Arrange urgent transport to a facility that can provide IV fluid therapy

• If the child is not vomiting give little sips (or small volumes through a syringe)
of ORS as frequently as possible
– If vomiting does not occur after 1-2 hours, give ORS at a rate of 5 ml/kg/hour

• If it is possible to insert a NG tube slowly rehydrate with ORS at 5ml/kg/hour

• If the child cannot be transported (e.g. roads blocked) give oral rehydration as
above and SC insulin 0.05 units/kg every 1-2 hours
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Admission for mild DKA

• Hyperglycemia without ketoacidosis or with only mild acidosis

• Admit to the hospital for

– Stabilization
– Education purpose
– Starting insulin therapy

• Start SC insulin therapy

– 0.7 U/kg/d if prepubertal
– 1.0 U/kg/d if at midpuberty
– 1.2 U/kg/d if at the end of puberty
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Summary
Steps in managing DKA

1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Definitive management of DKA
7. Discharge and follow-up

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THANK YOU!

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References

• Nelson textbook of pediatrics, 19th edition

• ISPAD Clinical Practice Consensus Guidelines 2009 Compendium
• Protocol on management of DKA, 2011
• Upto date 19.3

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