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Management of Diabetic Ketoacidosis in the PICU

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Management of Diabetic Ketoacidosis in the PICU. PICU Resident Lecture Series. DKA - A common PICU diagnosis. Incidence 4.6 – 8 per 1000 person years among people with diabetes Pediatric mortality rate is 1-2%. DKA causes profound dehydration. Hyperglycemia leads to osmotic diuresis - PowerPoint PPT Presentation

Text of Management of Diabetic Ketoacidosis in the PICU

Management of Diabetic Ketoacidosis in the PICU

Management of Diabetic Ketoacidosis in the PICUPICU Resident Lecture SeriesDKA - A common PICU diagnosisIncidence 4.6 8 per 1000 person years among people with diabetes

Pediatric mortality rate is 1-2%DKA causes profound dehydrationHyperglycemia leads to osmotic diuresisOften 10-15% down from baseline weight

Profound urinary free water and electrolyte lossFree water follows glucose into urineElectrolytes follow free water into urine

Electrolyte abnormalitiesPseudo-hyponatremia with hyperglycemiaSodium should rise with correction of glucoseProfound total-body K+ depletionUrinary loss, decreased intake, emesisInitial K+ may be high due to acidosis, low insulinAggressive K+ replacement necessary to prevent arrhythmiasPhosphate, magnesium, calcium require replacement

Initial DKA management - EDResuscitation aimed at shock reversalBegin with 10-20 mL/kg NS bolus, may repeat if signs of shock persistBolus fluids only necessary if signs of shock presentAvoid overly-aggressive fluid resuscitationConcern for inciting cerebral edema, though no clear data

Initial DKA management - EDNEVER give bicarbonateIncreases risk of cerebral edema

Begin insulin infusion at 0.1 units/kg/hrShould be initiated prior to leaving EDSQ or bolus insulin not indicatedPre-PICU arrivalOrder several bags of dextrose-containing and non-dextrose-containing IVF pre-PICU arrivalOften takes pharmacy 1 hour to custom-make IVFNo dextrose-containing fluids stocked in PICUFluid Management - PICU3 components to replacement fluidsDeficit (often 10-15% total body water deficit)Ongoing losses (polyuria, emesis)MaintenancePossible to calculate the above, or give:1.5X maintenance if moderately dehydrated2X maintenance if severely dehydratedInitial IVF Isotonic fluid with potassium

NS + 20 mEq/L KCl + 20 mEq/L KPhosStart with 40 mEq/L of potassium if K+ < 5K+ often split between KCl and KPhos to avoid hyperchloremic metabolic acidosisNS preferred to help prevent cerebral edemaAdding dextroseAdd dextrose to IVF when glucose < 300

2 bag system allows titration of dextrose based on glucoseBag 1: NS + 20 KCl + 20 KPhosBag 2: D10 NS + 20 KCl + 20 KPhosTitrating dextrose2 bag system example: Total IVF rate = 160 mL/hr

Fingerstick glucose = 280Bag 1: NS + 20 KCl + 20 KPhos @ 120 mL/hrBag 2: D10 NS + 20 KCl + 20 KPhos @ 40 mL/hrFluids Y together, dextrose concentration = D2.5Titrating dextrose2 bag system example: Total IVF rate = 160 mL/hr

Fingerstick glucose = 180Bag 1: NS + 20 KCl + 20 KPhos @ 40 mL/hrBag 2: D10 NS + 20 KCl + 20 KPhos @ 120 mL/hrFluids Y together, dextrose concentration = D7.5Frequent lab monitoring is essential in DKAGlucose q1 hour

Chem 10 , VBG q4 hoursTo correct venous pH to arterial pH, add 0.04

Serial UAs to monitor for resolution of glucosuria and ketonuria

DKA vs. Hyperglycemic Hyperosmolar Syndrome (HHS)HHS more likely in older, obese patients with Type II DMLab features of HHSMore severe hyperglycemia than DKALess severe or absent acidosisTrace or absent ketones in urineCan have normal serum bicarbSerum osmolality > 320Importance of InsulinInsulin is the only therapy that corrects the underlying pathophysiology in DKA

Increase dextrose as necessary to continue insulin infusion at 0.1 units/kg/hrDo NOT titrate insulin drip

Transitioning to SQ insulinMay consider transition when:Bicarb > 18, pH > 7.3, AG