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Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA) · PDF file Diabetic Ketoacidosis (DKA) 5th Edition, 2019 1 Illinois EMSC is a collaborative program between the Illinois Department

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  • Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)

    5th Edition, 2019

    1

    Illinois EMSC is a collaborative program between the Illinois Department of Public

    Health and the Ann & Robert H. Lurie Children’s Hospital of Chicago. Revision of

    this presentation was supported in part by: Grant 6 H33 MC 31621 from the

    Department of Health and Human Services Administration, Maternal and Child

    Health Bureau

  • Today, almost a century after the discovery of insulin, the most common cause of death in a child with diabetes, from a global perspective, is lack of access to insulin or improper use of insulin.

    Many children die even before their diabetes is diagnosed. Around the world, forces have united to make it come true that no child should die from diabetes or its complications.

    2

  • Illinois Emergency Medical Services for Children (EMSC)

     Illinois EMSC is a collaborative program between the

    Illinois Department of Public Health and Lurie

    Children’s Hospital of Chicago, aimed at improving

    pediatric emergency care within our state.

     Since 1994, Illinois EMSC has worked to enhance

    and integrate:

    • Pediatric education

    • Practice standards

    • Injury prevention

    • Data initiatives

    This educational activity is being presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters.

    3

    http://www.idph.state.il.us/ http://loyolamedicine.org/ http://www.luhs.org/depts/emsc/index.htm

  •  Define and explain pediatric hyperglycemia and DKA

     Highlight current standards of care regarding pediatric hyperglycemia and DKA management

     Provide educational resources to health care professionals to share with pediatric patients and families dealing with issues related to pediatric hyperglycemia and DKA

    Goals

    4

  • Suggested Citation: Illinois Emergency Medical Services for Children (EMSC), Pediatric Hyperglycemia and DKA, December 2018

    5

    EMSC Facility Recognition & Quality Improvement Committee

    Acknowledgements

    The Illinois EMSC Advisory Board gratefully acknowledges the commitment and

    dedication of the EMSC Facility Recognition & Quality Improvement Committee in

    revising this educational module (which was originally published in October 2012).

    Their contributions have led to this valuable resource and assists Illinois EMSC in

    striving toward the goal of improving pediatric emergency care within our state.

    To access a list of the committee members, click here.

    http://ilemsc.org/dka/EMSC_Fac_Rec_and_QI_Committee_DKA.pdf

  • Table of Contents

    Introduction

    Assessment

    Management

    Complications

    Patient Education

    Resources

    Test Your Knowledge

    References

    Appendices

     Appendix A: Assessment Tools

     Appendix B: “Two-bag System”

     Appendix C: Treatment Guidelines

    6

  • INTRODUCTION

    Return to Table of Contents 7

  • Purpose

    The purpose of this educational module is to enhance the care

    of pediatric patients who present with hyperglycemia and diabetic ketoacidosis (DKA) through appropriate:

     ASSESSMENT

     MANAGEMENT

     PREVENTION OF COMPLICATIONS

     DISPOSITION

     PATIENT & PARENT/CAREGIVER EDUCATION

    8

  • Objectives

    At the end of this module you will be able to:

     Describe the mechanisms of hyperglycemia and DKA

     Perform an initial assessment on a child who is experiencing hyperglycemia and DKA

     Describe the clinical presentation of a pediatric patient with DKA

     Understand the physiologic changes taking place in a pediatric patient with DKA

     Develop an effective management plan

     Discuss cerebral edema as a complication of pediatric DKA

     Develop a plan for appropriate admission, transfer or referral

     Formulate appropriate discharge instructions

    9

  • The following publications were the primary sources of

    information for this module, and will be referenced throughout:

    The American Diabetes Association (ADA)1

    Diabetic Ketoacidosis in Infants, Children, and Adolescents

    A consensus statement from the American Diabetes Association

    European Society for Paediatric Endocrinology (ESPE)2

    Lawson Wilkins Pediatric Endocrine Society (LWPES)2

    European Society for Paediatric Endocrinology / Lawson Wilkins Pediatric

    Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children

    and Adolescents

    International Society for Pediatric and Adolescent Diabetes (ISPAD)3

    Diabetic Ketoacidosis in Children and Adolescents with Diabetes

    ISPAD Clinical Practice Consensus Guidelines 2009 Compendium

    Main Resources

    10

  • Frequency of DKA

    DKA occurs in children with:

     New-onset of type 1 diabetes mellitus

     Established type 1 diabetes mellitus during risk episodes

     May occur in children with type 2 diabetes mellitus

    11

  • DKA Risk Factors

     Young children

     Poor diabetes control

     Previous episodes of DKA

     Missed insulin injections

     Insulin pump failure

     Infection or other illnesses

     Low socioeconomic status

     Lack of adequate health insurance

     Psychiatric disorders (i.e., eating disorders)

    12

  • Illinois EMSC Statewide DKA QI

     DKA record review (532 records total) - high percentage of cases reported documentation of: full set of vital signs, blood glucose level, and neurological status during initial assessment

     However, documentation of ongoing/hourly ED monitoring for same indicators was much less consistent

     Percentage of documentation even lower for hospitals that (on survey) reported ED ongoing monitoring was “not defined in policy” or performed “per physician decision”

    93%

    70%

    93%

    58% 52%

    37%

    0%

    20%

    40%

    60%

    80%

    100%

    Vital Signs Blood Glucose Neurological Assessment

    ED Monitoring of Pediatric DKA Patients (532 records)

    Initial Hourly

    13

  • Practice Deviations (within 1st hour of treatment)

    Guideline Recommendations

    Administer an IV fluid bolus 15-20 mL/kg 0.45% NaCl over the first hour

    The recommended fluid course is 10-20 mL/kg 0.9% NaCl over the first hour

    Administer an IV insulin drip of 0.1 units/kg/hour

    Current guidelines recommend administering insulin after the initial fluid resuscitation, not concurrently

    Administer an IV insulin bolus of 0.1 units/kg

    Current guidelines suggest IV insulin bolus may increase the risk of cerebral edema, and should not be used at the start of therapy

    Wait for more laboratory results before giving any fluids

    Current guidelines recommend initial IV fluid administration should begin immediately

    Illinois EMSC Statewide DKA QI

    ** Additional findings from the statewide QI project (responses to survey and case

    scenarios) seem to indicate concerning deviations from the current treatment

    guidelines for pediatric DKA patients within the first hour of treatment**

    14

  • Understanding Diabetes

    Diabetes mellitus, often referred to simply as diabetes.

    Diabetes is a condition in which the body:

     Does not produce enough insulin, and/or

     Does not properly respond to insulin

    Insulin is a hormone produced in the pancreas. Insulin enables

    cells to absorb glucose in order to turn it into energy.

    15

  • The cause of diabetes in children continues to be a mystery.

     Genetics

     Environmental factors

     Obesity

     Lack of exercise

    Diabetes: An Epidemic

    16

  • Type 1 vs. Type 2

    Type 1 diabetes Type 2 diabetes

    Diagnosed in children and young adults

    Typically diagnosed in adulthood

    Previously known as Juvenile Diabetes

    Also found in overweight children

    Insulin-dependent Non-insulin-dependent

    Body does not produce insulin

    Body fails to produce and properly use insulin

    17

  • Diabetes: Warning Signs

    18

  • Complications of blood glucose alterations

     Hypoglycemia

     Hyperglycemia

     Ketosis

     Acidosis

     DKA (Hyperglycemia + Ketosis + Acidosis)

    Blood Glucose Alterations

    Normal fasting blood glucose level 80 - 120 mg/dL

    19

  • Hypoglycemia

     Low blood glucose: treated when less than 70 mg/dL4

    Develops because the body doesn’t have enough glucose to burn energy

     Can happen suddenly

     Can be treated quickly and easily by eating or drinking a small amount of glucose rich food

    The signs and symptoms include:

    Low blood glucose

    Hunger

    Headache

    Confusion, shakiness, dizziness

    Sweating

    If h

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