Paediatric Diabetic Ketoacidosis

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Paediatric Diabetic Ketoacidosis. Scary Statistics. DKA = most common cause of death in children with IDDM. 25% of children newly diagnosed with DM1 present in DKA  15% in serious clinical status. All DKA admissions after diagnosis are avoidable! Costly  direct and indirect. Management. - PowerPoint PPT Presentation

Text of Paediatric Diabetic Ketoacidosis

  • Paediatric Diabetic Ketoacidosis

  • Scary StatisticsDKA = most common cause of death in children with IDDM.25% of children newly diagnosed with DM1 present in DKA 15% in serious clinical status.All DKA admissions after diagnosis are avoidable!Costly direct and indirect.

  • ManagementEmergency management ABC!!

    Airway ensure its patent. If comatose, insert an airway. Recurrent vomiting NG tube, aspirate, leave to open drainage.Breathing 100% O2 by face mask.Circulation insert IV cannula and take blood samples. ECG for T waves (hyperkalaemia)

  • ContdIf shocked (poor periph pulses, poor cap re-fill with tachycardia and/or hypotension) give 10 ml/kg 0.9% (normal) saline as a bolus, and repeat as necessary to a max of 30 ml/kg.

    NB. There is no evidence to support the use of colloids or other volume expanders in preference to crystalloids.

  • 2. Confirm the DiagnosisHistoryThirst/PolydidsiaPolyuria WeightNausea/vomitingAbdominal painDue to GLYCOSURIADue to infectious process or metabolic imbalance

  • ContdPhysical findings depressed, weak and dehydrated!!TachycardiaHypotensionDehydration mild, moderate, severe?Tachypnoea/KussmaulAbdo tenderness similar to acute appendicitis!!Fruity odour on breathAltered mental function neuro exam and GCS!!!FULL examination and WEIGH the child!!

  • ContdBiochemicalHigh blood glucose on finger-prick test.Glucose and ketones in urine.

  • Initial Investigations What should be checked and what they may show!Blood Glucose Hyperglycaemia (BM > 11mml/L)pH Metabolic acidosis (pH < 7.3)Blood Ketones KetonaemiaABGs Hypocapnic (blow off CO2)Base ExcessBicarbonate (low)U and Es Sodium and PotassiumFBC

  • Plus other investigations IF INDICATED!CXRCSFThroat swabBlood cultureUrinalysis

    NB. DKA may rarely be precipitated by sepsis, and fever is not part of DKA!

  • ObservationsStrict fluid balance.Urine output for every sample; test for ketones.Hourly BP and basic obs.Capillary ketones if available more sensitive.Hourly capillary blood glucoseTwice daily weight (fluid balance).Hourly or more freq neuro obs initially.Report any changes in conscious level, behaviour, ECG or onset of headache.

  • Management 1: FluidsVol of fluid Requirement = Maintenance + Deficit

    Deficit (litres) = %dehydration x body weight(convert to ml)No more than 10%

  • Maintenance requirements

    Age 0-2 years 80 ml/kg/24 hrs 3-5 70 ml/kg/24 hrs 6-9 60 ml/kg/24 hrs 10-14 50 ml/kg/24 hrs >15 30 ml/kg/24 hrs

  • Add calculated maintenance (for 48 hrs) and estimated deficit, subtract the amount already given as resuscitation fluid, and give the total vol evenly over the next 48 hrs, i.e.

    Hourly = 48 hr maint + deficit resus fluid rate 48

  • Example:A 20 kg 6-yr-old boy who is 10% dehydrated, and who has already had 20 ml/kg saline, will require:10% x 20 kg = 2000 mls deficitPlus 60 ml x 20 kg = 1200 mls maitenence/24h = 2400 mls over 48hMaintenance + deficit = 4400 mls over 48hMinus 20kg x 20ml = 400 mls resus fluid= 4000 mls over 48h = 83 mls/hr!!NB. Do not include continuing urinary losses in your calculations.

  • Type of Fluid:Initially use 0.9% saline.Once blood glucose to 14-17 mmol/L, add glucose.If this occurs in first 6 hrs discuss with senior.After 6 hrs 0.45% saline/5% dextrose.

    Oral Fluids:None in severe dehydration, impaired consciousness and acidosis.Only offered after substantial clinical improvement and no vomiting.Need for IV infusions to be reduced.

  • 2. PotassiumOnce resus complete, commence immediately.Always a massive depletion of total body K+, even if low to start with, because of insulin.Initially add 20 mmol KCl to every 500ml bag of fluid (40mmol/L).Check U&Es 2h after resus, then at least 4 hourly. Adjust K+ replacements accordingly.ECG observe for T wave changes.

  • 3. InsulinEssential to switch off ketogenesis and reverse the acidosis.Continuous low-dose IV infusion.Run at 0.1 U/kg/hr maintain at this rate.If rate of glucose fall exceeds 5 mmol/L/hr, or falls to ~14-17mmol/L, add dextrose (5-10%) to IV fluids.Once pH > 7.3, BM 14-17, and dextrose-containing fluid commenced, consider insulin rate, but to no less than 0.5 U/kg/hr.

  • 4. BicarbonateVirtually never necessary.Always consult senior before administering.Only purpose is to improve cardiac contractility in severe shock.

  • 5. PhosphateAlways a depletion.No evidence in adults or children that replacement has any clinical benefit and phosphate administration may lead to hypocalcaemia.

  • Cerebral OedemaUnpredictable.More freq in younger children with newly diagnosed diabetes.Mortality ~ 25%.Unknown cause.Aim of DKA therapy slow correction of metabolic abnormalities - incidence of cerebral oedema.

  • Signs and SymptomsHeadache and slowing of HR.Change in neuro status (restlessness, irritability, increased drowsiness, incontinence)Specific neuro signs (e.g. cranial nerve palsies)Rising BP, decreasing O2 saturationAbnormal posturingMore dramatic changes convulsions, papilloedema, resp arrest late signs assoc with extremely poor prognosis.

  • ManagementIf suspected inform senior staff immediatelyExclude hypoglycaemiaGive Mannitol 1 g/kg stat (= 5ml/kg Mannitol 20% over 20 mins) or hypotonic saline (5-10mls/kg over 30 mins) ASAP!!!Restrict IV fluids to 2/3 maintenance and replace deficit over 72 rather than 48 hrs.PICU.CT exclude other diagnoses.Repeat dose of Mannitol after 2h if no response.

  • Other ComplicationsHypoglycaemia and Hypokalaemia avoid by careful monitoring and adjustment of infusion rates.Systemic Infections Abx not given routinely unless severe bacterial infection suspected.Aspiration Pneumonia Avoid by NG tube in vomiting child with impaired consciousness