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Presentation title Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

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Text of Presentation title Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

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Presentation title Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA) Slide 2 Slide No 2Slide no 2 1 2 3 Managing DKA Surgery in children with diabetes Treating and preventing hypoglycaemia Programme Slide 3 Slide No 3 Diabetic Ketoacidosis Occurs when there is insufficient insulin action Commonly seen at diagnosis Is a life-threatening event Child should be transferred as soon as possible to the best available site of care with diabetes experience Initiate care at diagnosis Slide no 3 Slide 4 Slide No 4 Type 1 Diabetes Increased urine Dehydration Thirst Slide 5 Slide No 5 DKA Weight loss Ketones Nausea Vomiting Abdominal pain Altered level of consciousness Shock Dehydration Liver Muscle Fat Weight loss Ketones Slide 6 Slide No 6 Clinical features Slide no 6 Pathophysiology (Whats wrong) Clinical features (What do you see) Elevated blood glucose High lab blood glucose, glucose meter reading or urine glucose, polyuria, polydypsia DehydrationSunken eyes, dry mouth, decreased skin turgor, decreased perfusion (shock rare) Altered electrolytesIrritability, change in level of consciousness Metabolic acidosis (ketosis) Acidotic breathing, nausea, vomiting, abdominal pain, altered level of consciousness Slide 7 Slide No 7 Managing DKA Refer to best available site of care whenever possible Need: Appropriate nursing expertise (preferably a high level of care) Laboratory support Clinical expertise in management of DKA Written guidelines should be available Document and use the form Slide no 7 Slide 8 Slide No 8 DKA monitoring form Slide 9 Slide No 9 DKA monitoring DKA protocol available to the clinic Slide 10 Slide No 10 Principles of DKA management (1) 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 10 Slide 11 Slide No 11 Principles of DKA Management (2) 1.Correction of shock or decreased peripheral circulation quick phase 2.Correction of dehydration - slow phase Do not start insulin until the child has been adequately resuscitated, i.e. good perfusion and good circulation Slide no 11 Slide 12 Slide No 12 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 12 Slide 13 Slide No 13 Assessment History and examination including: Severity of dehydration. If uncertain about this, assume 10% dehydration in significant DKA Level of consciousness Determine weight Determine glucose and ketones Laboratory tests: blood glucose, urea and electrolytes, haemoglobin, white cell count, HbA1c Slide no 13 Slide 14 Slide No 14 Resuscitation (1) Ensure appropriate life support (Airway, Breathing, Circulation, etc.) Give oxygen to children with impaired circulation and/or shock Set up a large IV cannula/intra-osseous access. Give fluid (saline or Ringers Lactate) at 10ml/kg over 30 minutes if in shock, otherwise over 60 min. Repeat boluses of 10 ml/kg until perfusion improves Slide no 14 Slide 15 Slide No 15 Resuscitation (2) If no IV available, insert nasogastric tube or set up intraosseous or clysis infusion Give fluid at 10 ml/kg/hour until perfusion improves, then 5 ml/kg/hour Use normal saline, half-strength Darrows solution with dextrose, or oral rehydration solution Decrease rate if child has repeated vomiting Transfer to appropriate level of care Slide no 15 Slide 16 Slide No 16 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 16 Slide 17 Slide No 17 Rehydration (1) Rehydrate with normal saline Provide maintenance and replace a 10% deficit over 48 hours Do not add urine output to the replacement volume Reassess clinical hydration regularly. Once the blood glucose isSlide 18 Slide No 18 Rehydration (2) If IV/intra-osseous access is not available: Rehydrate orally with oral rehydration solution (ORS) Use nasogastric tube at a constant rate over 48 hours If a NG tube tube is not available, give ORS by oral sips at a rate of 1 ml/kg every 5 min if decreased peripheral circulation, otherwise every 10 min. Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible Slide no 18 Slide 19 Slide No 19 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 19 Slide 20 Slide No 20 Insulin therapy (1) Start insulin after your ABCs (treat shock, start fluids) - stability has improved Insulin infusion of any short acting insulin at 0.1U/kg/hour (0.05 U/kg/hr if younger than 5 years) Rate controlled with the best available technology (infusion pump) Do not correct glucose too rapidly. Aim for decrease of 5 mmol/l per hour Slide no 20 Slide 21 Slide No 21 Insulin therapy (2) Example: A 24 kg child will need 2.4 U/hour Put 24 U short acting insulin into 100 ml saline and run at 10 ml/hour Equivalent to 0.1 U/kg/hour Younger children: lower rate e.g. 0.05 U/kg/hour Slide no 21 Slide 22 Slide No 22 Insulin therapy (3) If no suitable control of the rate of the insulin infusion is available OR No IV access use sub-cutaneous or intra-muscular insulin. Give 0.1 U/kg of short-acting regular or analogue insulin subcutaneously or IM into the upper arm Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible Slide no 22 Slide 23 Slide No 23 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 23 Slide 24 Slide No 24 Electrolyte deficits The most important is potassium Every child in DKA needs potassium replacement Other electrolytes can only be assessed with a laboratory test Obtain a blood sample for determination of electrolytes at diagnosis of DKA Slide no 24 Slide 25 Slide No 25 ECG and Potassium Levels Slide 26 Slide No 26 Potassium (1) Levels determined by laboratory test If not available, can use ECG (T waves) Start potassium replacement once serum value known or patient passes urine If no lab value or urine output within 4 hours of starting insulin, start potassium replacement Slide no 26 Slide 27 Slide No 27 Potassium (2) Add KCl to IV fluids at a concentration of 40 mmol/l (20 ml of 15% KCl has 40 mmol/l of potassium) If IV potassium not available, replace by giving the child fruit juice or bananas. If rehydrating with oral rehydration solution (ORS), no added potassium is needed Slide no 27 Slide 28 Slide No 28 Potassium (3) Monitor serum potassium 6-hourly, or as often as is possible In sites where potassium cannot be measured, consider transfer of the child to a facility with resources to monitor potassium and electrolytes Slide no 28 Slide 29 Slide No 29 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 29 Slide 30 Slide No 30 Acidosis Usually due to ketones Poor circulation will make it worse Correction not recommended unless the acidosis is very profound If bicarbonate is considered necessary, cautiously give 1-2 mmol/kg over 60 minutes. Usually not needed Slide no 30 Slide 31 Slide No 31 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 31 Slide 32 Slide No 32 Infection Infection can precipitate the development of DKA Often difficult to exclude infection in DKA, as the white cell count is often elevated because of stress If infection is suspected, treat with broad-spectrum antibiotics Slide no 32 Slide 33 Slide No 33 Principles 1.Correction of shock 2.Correction of dehydration 3.Correction of hyperglycaemia 4.Correction of deficits in electrolytes 5.Correction of acidosis 6.Treatment of infection 7.Treatment of complications Slide no 33 Slide 34 Slide No 34 Complications Electrolyte abnormalities Cerebral oedema Rare but often fatal Often unpredictable Related to severity of acidosis, rate and amount of rehydration, severity of electrolyte disturbance, degree of glucose elevation and rate of decline of blood glucose Causes raised intra-cranial pressure Can lead to death Slide no 34 Slide 35 Slide No 35 Cerebral Oedema (1) Presents with Change in neurological state (restlessness, irritability, increased drowsiness or seizures) Headache Increased blood pressure and slowing heart rate Decreasing respiratory effort Focal neurological signs Diabetes insipidus: unexpected/increased urination Slide no 35 Slide 36 Slide No 36 Cerebral Oedema (2) Check blood glucose Reduce the rate of fluid administration by one-third. Give hypertonic saline (3%), 5 ml/kg over 30 minutes - repeat if needed Mannitol 0.5-1 g/kg IV over 20 minutes may be an alternative Elevate the head of the bed Nasal oxygen Intubation may be necessary for a patient with impending respiratory failure Slide no 36 Slide 37 Slide No 37 Monitoring Use forms: Record hourly: heart rate, blood pressure, respiratory rate, level of consciousness, glucose. Monitor urine ketones Record fluid intake, insulin therapy and urine output Repeat urea & electrolytes every 4-6 hours Once the blood glucose is less than 15 mmol/l, add dextrose to the saline Transition to subcutaneous insulin Slide no 37 Slide 38 Slide No 38 DKA In Summary Life threatening condition Req

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