Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA) .Pediatric Hyperglycemia and Diabetic Ketoacidosis

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  • Pediatric Hyperglycemia and Diabetic Ketoacidosis (DKA)

    5th Edition, 2017

    1

    Illinois Emergency Medical Services for Children

  • 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 within the

    Illinois Department of Public Health, 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.

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    http://www.idph.state.il.us/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, April 2017

    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.

  • 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 Contents7

  • 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

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  • 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

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  • The following publications were the primary sources of

    information for this module, and will be referenced throughout:

    American Diabetes Association (ADA)1

    Standards of Medical Care in Diabetes 2017. Diabetes Care.

    American Diabetes Association (ADA)2

    Diabetic Ketoacidosis in Infants, Children, and Adolescents

    A consensus statement from the American Diabetes Association

    European Society for Paediatric Endocrinology (ESPE)3

    Lawson Wilkins Pediatric Endocrine Society (LWPES)3

    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)4

    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

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  • 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)

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  • 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

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  • 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.

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  • 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 60 mg/dL

    Develops because the body doesnt 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 hypoglycemia is suspected, check the blood glucose concentration

    20

  • Hyperglycemia

    High blood glucose: treated when greater than 200 mg/dL

    Develops when the body has too much glucose in the blood

    Serious problem if not treated

    A major cause of many of the complications in children with diabetes

    The signs and symptoms include:

    High blood glucose

    High levels of glucose in the urine

    Frequent urination

    Increased thirst

    If hyperglycemia is suspected, check the blood glucose concentration

    21

  • Hypoglycemia vs. Hyperglycemia

    Low blood glucose (less than 60 mg/dL)

    Signs and symptoms include:

    Shakiness

    Dizziness

    Sweating

    Hunger

    Headache

    Pale skin color

    Mental or behavior changes

    Lethargy

    Clumsy or jerky movements

    Seizure

    Difficulty concentrating

    Tingling sensations around the

    mouth

    Signs and symptoms include:

    Classic symptoms:

    Polyphagia (excessive hunger)

    Polyuria (excessive urine/urination)

    Polydipsia (excessive thirst)

    Other symptoms might in