paediatric diabetic ketoacidosis

Paediatric Paediatric Diabetic Diabetic

KetoacidosisKetoacidosis

Scary StatisticsScary Statistics

DKA = most common cause of death DKA = most common cause of death in children with IDDM.in children with IDDM.

25% of children newly diagnosed 25% of children newly diagnosed with DM1 present in DKA with DM1 present in DKA 15% in 15% in serious clinical status.serious clinical status.

AllAll DKA admissions after diagnosis DKA admissions after diagnosis are avoidable!are avoidable!

Costly Costly direct and indirect. direct and indirect.

ManagementManagement

1)1) Emergency management Emergency management ABC!! ABC!!

1.1. AirwayAirway ensure it’s patent. If ensure it’s patent. If comatose, insert an airway. Recurrent comatose, insert an airway. Recurrent vomiting – NG tube, aspirate, leave to vomiting – NG tube, aspirate, leave to open drainage.open drainage.

2.2. Breathing Breathing 100% O 100% O22 by face mask. by face mask.3.3. CirculationCirculation insert IV cannula and insert IV cannula and

take blood samples. ECG for T waves take blood samples. ECG for T waves (hyperkalaemia)(hyperkalaemia)

Cont’dCont’d

If If shocked shocked (poor periph pulses, poor cap (poor periph pulses, poor cap re-fill with tachycardia and/or re-fill with tachycardia and/or

hypotension) give hypotension) give

10 ml/kg 0.9% (normal) saline as a bolus, 10 ml/kg 0.9% (normal) saline as a bolus, and repeat as necessary to a max of 30 and repeat as necessary to a max of 30

ml/kg. ml/kg.

NB. There is NB. There is nono evidence to support the evidence to support the use of colloids or other volume expanders use of colloids or other volume expanders

in preference to crystalloids.in preference to crystalloids.

2. Confirm the Diagnosis2. Confirm the Diagnosis

HistoryHistory Thirst/PolydidsiaThirst/Polydidsia PolyuriaPolyuria WeightWeight Nausea/vomitingNausea/vomiting Abdominal painAbdominal pain

Due to GLYCOSURIA

Due to infectious process or metabolic imbalance

Cont’dCont’d

Physical findings Physical findings depressed, weak and depressed, weak and dehydrated!!dehydrated!!

TachycardiaTachycardia HypotensionHypotension Dehydration Dehydration mild, moderate, severe? mild, moderate, severe? Tachypnoea/KussmaulTachypnoea/Kussmaul Abdo tenderness Abdo tenderness similar to acute appendicitis!! similar to acute appendicitis!! Fruity odour on breathFruity odour on breath Altered mental function Altered mental function neuro exam and neuro exam and

GCS!!!GCS!!! FULL examination and WEIGH the child!!FULL examination and WEIGH the child!!

Cont’dCont’d

BiochemicalBiochemical High blood glucose on finger-prick High blood glucose on finger-prick

test.test. Glucose and ketones in urine.Glucose and ketones in urine.

Initial Investigations– What Initial Investigations– What should should be checked and be checked and what they may show!what they may show!

Blood GlucoseBlood Glucose Hyperglycaemia ( Hyperglycaemia (BM > BM > 11mml/L)11mml/L)

pHpH Metabolic acidosis ( Metabolic acidosis (pH < 7.3)pH < 7.3) Blood KetonesBlood Ketones Ketonaemia Ketonaemia ABGsABGs Hypocapnic (‘blow off’ CO Hypocapnic (‘blow off’ CO22)) Base ExcessBase Excess BicarbonateBicarbonate (low) (low) U and EsU and Es Sodium and Potassium Sodium and Potassium FBCFBC

Plus Plus other investigations IF other investigations IF INDICATED!INDICATED!

CXRCXR CSFCSF Throat swabThroat swab Blood cultureBlood culture UrinalysisUrinalysis

NB. DKA may NB. DKA may rarelyrarely be precipitated be precipitated by sepsis, and fever is by sepsis, and fever is notnot part of part of DKA!DKA!

ObservationsObservations Strict fluid balance.Strict fluid balance. Urine output for Urine output for everyevery sample; test for sample; test for

ketones.ketones. Hourly BP and basic obs.Hourly BP and basic obs. Capillary ketones if available – more Capillary ketones if available – more

sensitive.sensitive. Hourly capillary blood glucoseHourly capillary blood glucose Twice daily weight (fluid balance).Twice daily weight (fluid balance). Hourly or more freq neuro obs initially.Hourly or more freq neuro obs initially. Report Report anyany changes in conscious level, changes in conscious level,

behaviour, ECG or onset of headache.behaviour, ECG or onset of headache.

Management 1: FluidsManagement 1: Fluids

Vol of fluidVol of fluid

Requirement = Maintenance + Requirement = Maintenance + DeficitDeficit

Deficit (litres) = %dehydration x Deficit (litres) = %dehydration x body weightbody weight

(convert to ml)(convert to ml)

No more than 10%

MaintenanceMaintenance requirements requirements

Age 0-2 years 80 ml/kg/24 Age 0-2 years 80 ml/kg/24 hrshrs

3-5 70 ml/kg/24 hrs3-5 70 ml/kg/24 hrs

6-9 60 ml/kg/24 hrs6-9 60 ml/kg/24 hrs

10-14 50 ml/kg/24 hrs10-14 50 ml/kg/24 hrs

>15 30 ml/kg/24 hrs>15 30 ml/kg/24 hrs

Add calculated maintenance (for 48 Add calculated maintenance (for 48 hrs) and estimated deficit, subtract hrs) and estimated deficit, subtract

the amount already given as the amount already given as resuscitation fluid, and give the total resuscitation fluid, and give the total vol vol evenlyevenly over the next 48 hrs, i.e. over the next 48 hrs, i.e.

Hourly = Hourly = 48 hr maint + deficit – 48 hr maint + deficit – resus fluidresus fluid

rate 48 rate 48

Example:Example:

A 20 kg 6-yr-old boy who is 10% A 20 kg 6-yr-old boy who is 10% dehydrated, and who has already had 20 dehydrated, and who has already had 20 ml/kg saline, will require:ml/kg saline, will require:

10% x 20 kg = 2000 mls deficit10% x 20 kg = 2000 mls deficit PlusPlus 60 ml x 20 kg = 1200 mls 60 ml x 20 kg = 1200 mls

maitenence/24hmaitenence/24h

= 2400 mls over 48h= 2400 mls over 48h Maintenance + deficit = 4400 mls over Maintenance + deficit = 4400 mls over

48h48h MinusMinus 20kg x 20ml = 400 mls resus fluid 20kg x 20ml = 400 mls resus fluid

= 4000 mls over 48h = 83 mls/hr!!= 4000 mls over 48h = 83 mls/hr!!NB. Do not include continuing urinary losses in your NB. Do not include continuing urinary losses in your

calculations.calculations.

Type of Fluid:Type of Fluid: Initially use 0.9% saline.Initially use 0.9% saline. Once blood glucose Once blood glucose to 14-17 mmol/L, add to 14-17 mmol/L, add

glucose.glucose. If this occurs in first 6 hrs If this occurs in first 6 hrs discuss with discuss with

senior.senior. After 6 hrs After 6 hrs 0.45% saline/5% dextrose. 0.45% saline/5% dextrose.

Oral Fluids:Oral Fluids: None in severe dehydration, impaired None in severe dehydration, impaired

consciousness and acidosis.consciousness and acidosis. Only offered after substantial clinical Only offered after substantial clinical

improvement and no vomiting.improvement and no vomiting. Need for IV infusions to be reduced.Need for IV infusions to be reduced.

2. Potassium2. Potassium

Once resus complete, commence Once resus complete, commence immediately.immediately.

AlwaysAlways a massive depletion of total body K a massive depletion of total body K++, , even if low to start with, because of insulin.even if low to start with, because of insulin.

Initially add 20 mmol KCl to every 500ml bag Initially add 20 mmol KCl to every 500ml bag of fluid (40mmol/L).of fluid (40mmol/L).

Check U&Es 2h after resus, then at least 4 Check U&Es 2h after resus, then at least 4 hourly. Adjust K+ replacements accordingly.hourly. Adjust K+ replacements accordingly.

ECG ECG observe for T wave changes. observe for T wave changes.

3. Insulin3. Insulin

Essential to switch off ketogenesis and Essential to switch off ketogenesis and reverse the acidosis.reverse the acidosis.

Continuous low-dose IV infusion.Continuous low-dose IV infusion. Run at 0.1 U/kg/hr Run at 0.1 U/kg/hr maintain at this rate. maintain at this rate. If rate of glucose fall exceeds 5 mmol/L/hr, If rate of glucose fall exceeds 5 mmol/L/hr,

or falls to ~14-17mmol/L, add dextrose (5-or falls to ~14-17mmol/L, add dextrose (5-10%) to IV fluids.10%) to IV fluids.

Once pH > 7.3, BM 14-17, and dextrose-Once pH > 7.3, BM 14-17, and dextrose-containing fluid commenced, consider containing fluid commenced, consider insulin rate, but to no less than 0.5 U/kg/hr.insulin rate, but to no less than 0.5 U/kg/hr.

4. Bicarbonate4. Bicarbonate

Virtually Virtually nevernever necessary. necessary. Always Always consult senior before consult senior before

administering.administering. Only purpose Only purpose is to improve cardiac is to improve cardiac

contractility in severe shock.contractility in severe shock.

5. Phosphate5. Phosphate

Always a depletion.Always a depletion. No evidence in adults or children No evidence in adults or children

that replacement has any clinical that replacement has any clinical benefit benefit andand phosphate phosphate administration may lead to administration may lead to hypocalcaemia.hypocalcaemia.

Cerebral OedemaCerebral Oedema

Unpredictable.Unpredictable. More freq in younger children with More freq in younger children with

newly diagnosed diabetes.newly diagnosed diabetes. Mortality ~ 25%.Mortality ~ 25%. Unknown cause.Unknown cause. Aim of DKA therapy Aim of DKA therapy slowslow correction correction

of metabolic abnormalities - of metabolic abnormalities - incidence of cerebral oedema.incidence of cerebral oedema.

Signs and SymptomsSigns and Symptoms Headache and slowing of HR.Headache and slowing of HR. Change in neuro status (restlessness, Change in neuro status (restlessness,

irritability, increased drowsiness, irritability, increased drowsiness, incontinence)incontinence)

Specific neuro signs (e.g. cranial nerve Specific neuro signs (e.g. cranial nerve palsies)palsies)

Rising BP, decreasing O2 saturationRising BP, decreasing O2 saturation Abnormal posturingAbnormal posturing More dramatic changes More dramatic changes convulsions, convulsions,

papilloedema, resp arrest papilloedema, resp arrest late signs late signs assoc with extremely poor prognosis.assoc with extremely poor prognosis.

ManagementManagement If suspected – If suspected – inform senior staff inform senior staff

immediatelyimmediately Exclude hypoglycaemiaExclude hypoglycaemia Give Mannitol 1 g/kg stat (= 5ml/kg Mannitol Give Mannitol 1 g/kg stat (= 5ml/kg Mannitol

20% over 20 mins) 20% over 20 mins) oror hypotonic saline hypotonic saline (5-10mls/kg over 30 mins) ASAP!!!(5-10mls/kg over 30 mins) ASAP!!! Restrict IV fluids to 2/3 maintenance and Restrict IV fluids to 2/3 maintenance and

replace deficit over 72 rather than 48 hrs.replace deficit over 72 rather than 48 hrs. PICU.PICU. CT CT exclude other diagnoses. exclude other diagnoses. Repeat dose of Mannitol after 2h if no Repeat dose of Mannitol after 2h if no

response.response.

Other ComplicationsOther Complications

Hypoglycaemia and Hypokalaemia Hypoglycaemia and Hypokalaemia avoid by careful monitoring and avoid by careful monitoring and adjustment of infusion rates.adjustment of infusion rates.

Systemic Infections Systemic Infections Abx not given Abx not given routinely unless severe bacterial routinely unless severe bacterial infection suspected.infection suspected.

Aspiration Pneumonia Aspiration Pneumonia Avoid by Avoid by NG tube in vomiting child with NG tube in vomiting child with impaired consciousness impaired consciousness