Paeds DKA

February 2022
Objectives
• Understand the principles of management of the child with
Diabetic Ketoacidosis (DKA)
• Be familiar with the Paeds DKA order set to be able to
anticipate nursing actions
• Be familiar with complications of DKA and their treatment
Our patient
• 4 year old girl
• Comes to ER at 1830 with abdominal pain and vomiting
• History:
• 2 weeks of polyuria, polydypsia.
• Weight loss of 4 kg in the last 2 months.
• Seen in the community yesterday – sent for blood work.
Initial presentation in Ontario
• DKA as initial presentation –
18.6%
• Younger kids are missed more
often:
• Age ≤ 3 years – 39.7% in DKA
• Age > 3 years – 16.3% in DKA

• In the week prior to diagnosis:

• 38.8% of children with DKA were
seen by a physician at least once.
Bui et al, J Peds 2010
Back to our case:
• Physical Assessment:
• Lethargic
• BP: 100/60, HR: 140, RR: 30 (Kussmaul’s breathing, fruity odour).
• Cap refill – 3 seconds.
• Rest of exam – unremarkable.
• Weight= 29.5 kg

• Labs:
• Glucose - 35 mmol/L
• VBG:
• pH: 7.12 (7.32-7.43)
• pCO2 – 30 mmHg (40-50)
• HCO3 – 5 mmol/L (22-29)
• B.E. – (-17) (-2-3)
• Electrolytes – Na – 138 mEq/L, K – 4.5 mEq/L
• Urinalysis positive for ketones and glucose
Diabetic Ketoacidosis
• A state of absolute or relative deficiency of insulin:
• Hyperglycemia
• Dehydration
• Production of keto-acids and subsequent metabolic
acidosis
 Insulin Deficiency

Hyperglycemia Lipolysis

Osmotic Diuresis
Loss of cations including K Ketogenesis

Dehydration
Metabolic acidosis

Cardiovascular and renal CNS changes

changes
Causes of DKA
• Initial presentation of type 1 DM
• In a known diabetic:
• Pump malfunction
• Insulin omission
• Intercurrent illness
• Stress
Principles of management
1. Lack of Insulin -> Administration of insulin to reverse acidosis
• Give at a rate of 1 unit/kg/hr as long as the child is acidotic
• As the blood sugar falls= Increase glucose concentration in IV solution
• Do not stop insulin unless you’re at minimum rate and the child is hypoglycemic

2. Dehydration -> Fluids

• Slow correction to prevent cerebral edema

3. Potassium Depletion -> give K+

• Might be in the normal range, but this level is driven by the acidosis
• With correction of the acidosis – K level will plummet
• Early supplementation of K is crucial!!

**High blood sugar? We don’t care**

What should we do for our patient?
• Paeds DKA Order Set initiated:
• Initial NS bolus started in the ED (over 30 minutes)
• NS maintenance infusion started in the ED at 5 mL/kg/hr
• After 1 hour, insulin infusion and NS maintenance started in the ED

• Orders:
• 0.1 units/kg/hr for the insulin infusion and
• Rate for NS infusion should keep patients total IV fluid intake at 5
mL/kg/hr (147.5 mL/hr)

• Your patient weighs 29.5 kg so what rate should these be infusing at?
• Insulin should be at 29.5 mL/ hr
• TFI= 29.5 x 5= 147.5 mL/hr.
• 147.5- 29.5 for insulin= 118 mL/hr for NS
What do you need to do when….
1. After 30 minutes on the insulin infusion, your patient pees…
- Change maintenance infusion to NS + 40 KCl

2. 4 hours later you are reviewing most recent bloodwork…

2130 2336

Glucose: 18.7 14.4

**What should we do?

Change solution to D10/NS + 40 KCl
Back to our patient…
• All of a sudden, our patient wets the bed and seems
confused.
• What’s going on? What should we do?
• Potential issues:
• Cerebral edema?
• Hypoglycemia?

• Call physician, elevate HOB and check glucose

Cerebral Edema
• 1% of children in DKA
• 20-90% mortality
• Mechanism – unclear
• Risk Factors:
• Younger children
• Children with newly diagnosed diabetes
• The use of bicarbonate therapy for correction of the acidosis in DKA
Cerebral Edema
• Diagnosis:
• Altered state of consciousness
• Confusion or abnormal neurological examination
• Sustained bradycardia
• Management:
• Call physician
• Reduce fluid rate
• Mannitol: 0.5- 1g/kg over 20 minutes
• Hypertonic Saline (3%) – 5 mL/kg over 15 minutes.
If patient is not correcting…
• Bloodwork not improving:
• Check your infusion rate
• Change insulin bag and tubing

**Remember: Blood glucose level is not worrisome- it is

important to see that the acidosis is correcting**
The next morning…
• Acidosis is corrected

• Your patient looks much better and is hungry

36.7
7.37
44
26
-1
POCT Glucose: 8.2
Switching over to SC insulin
• Give the SC dose
• Disconnect the infusion 15-30 minutes afterwards.
 Physiologic Insulin Secretion:
24-hour Profile
50
Insulin Prandial insulin
(µU/mL) 25
0 Basal insulin

Breakfast Lunch Dinner

150
Glucose 100 Prandial glucose
(mg/dL)
50
Basal glucose
0
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
AM PM

Time of day
 MDI (Multiple Daily Injection)
Regimen
• More physiologic
• Flexibility with meal times and
amount of food consumed.
• Requires 4 injections a day
(at least)
• Requires carbohydrate counting.

• Calculation of insulin dose:

• Insulin/Carbohydrate ratio.
• Correction (sensitivity) factor
Starting dose…
• Total daily dose: 0.5-0.8 units/kg/d
• MDI:
• 50% as Lantus
• 50% - divide equally to the 3 meals

• All new diagnosis paeds patients in the hospital

should be started on MDI
 Correction/ Sensitivity Factors and
Insulin: Carb Ratios
• Correction/ Sensitivity Factor: how much insulin should be taken to
bring the current blood sugar back to an ideal level. It is expressed as
a ratio and is the same for each meal the patient eats
• 1 unit of insulin: ____ mmol/L glucose

• Insulin: Carbohydrate ratio: how much insulin the patients should

take based on how many carbs will be consumed at that meal. The
paediatrician may order a different ratio for different meals so check
your orders carefully!
• 1 unit of insulin: ____ grams carbohydrate

***Both of these will be ordered by the paediatrician ***

How do I calculate these?
• Carb Counting:
• Determine what patient is hoping to eat and get nutrition info: take total
carbs and subtract fibre (fibre doesn’t raise blood sugar).
• I.e. Chicken noodle soup and muffin from Tim Hortons= 78 g carbs – 3 g fibre= 75 g
• Calculate insulin dose based on insulin carb ratio
• I.e. insulin: carb ratio of 1:12
• 75/ 12= 6.25 units insulin (rounded to 6 units)

• Correction Factor:
• Check blood sugar and determine what her target blood sugar is.
• I.e. for our patient, goal is 6 mmol/ L and her current sugar is 10.
• Her correction factor is 1 unit insulin: 3 mmol/L glucose meaning we give 1 unit for
every 3 mmol she is above 6.
• She is 4 greater than the goal so 4/3= 1.3 or 1 unit of insulin

**So altogether we will give 6 + 1= 7 units

of insulin before lunch**
•Questions?