![CALCULATIONS
SERUM OSMOLALITY:
2[NA+K]+ (GLUCOSE/18) + BUN/2.8
SERUM NA:
CORRECTED NA =
MEASURED NA + (1.6)(GLUCOSE - 100)/100
ANION GAP:
[NA] – ([CL]+[HCO3])
NORMALLY 12+/-2 MMOL/L](https://image.slidesharecdn.com/dka-200110105109/85/DKA-in-children-12-320.jpg)
DKA in children
- 1. DIABETIC KETOACIDOSIS IN CHILDREN D:MH RADI SENIOR REGESTRAR OF PEDIATRICS
- 2. DEFINITION • Hyperglycemia BG > 200 mg/dl (11 mmol/l) (young or partially treated children, pregnant adolescents may present with “euglycemic ketoacidosis”) • Venous pH <7.3 and/or bicarbonate <15 mmol/L • mild DKA pH <7.3 bicarbonate <15 • moderate pH <7.2 bicarbonate <10 • severe pH <7.1 bicarbonate < 5 • Glucosuria and ketonuria/ketonemia (β-HOB)
- 3. INCIDENCE OF DKA AT ONSET • Wide geographic variation in DKA rates at diabetes onset: 15 -70% • More common in developing countries • DKA rates inversely related to incidence of type 1 diabetes
- 4. RISK FACTORS FOR DKA AT ONSET • Age <12 yrs • No first degree diabetic relative • Lower socioeconomic status • High dose glucocorticoids, atypical antipsychotics, diazoxide and some immunosuppresive drugs • Poor access to medical care
- 5. DKA IN CHILDREN WITH ESTABLISHED T1DM • The risk of DKA varies from 1:10 to 1:100 /p-yr • Poor metabolic control or previous DKA risk • Adolescent girls • Children with psychiatric disorders, including those with eating disorders • Lower socio-economic status • Inappropriate interruption of insulin pump therapy
- 6. PROPORTION OF CHILDREN WITH RECURRENT DKA 0 1 2+ • 60% of DKA episodes occurred in 5% of children who had 2 or more events # of DKA events 5%
- 7. Diabetes Care 2006 29:1150-1159
- 8. SIGNS OF DKA • Vomiting • Increased urination • Abdominal pain • Fruity odor to breath • Dry mouth and tongue • Drowsiness • Deep breathing • Coma • Death
- 9. PHYSICAL EXAM • Perfusion • Vital Signs - including weight • Hydration • Mental Status • Evidence for insulin resistance
- 10. CEREBRAL EDEMA • Know what to look for • Altered mental status/ severe headache • Recurrence of vomiting • Changes in pupil size, seizures, bradycardia • Clinical worsening despite improving lab values • CT/ MRI changes may not be seen in early cerebral edema
- 11. TIME OF ONSET OF NEUROLOGICAL COMPROMISE (HOURS) 0 2 4 6 8 10 12 14 16 0-2.9 3-5.9 6-8.9 9-11.9 12-14.9 >15 # of patients Muir A, et al, Diab Care. July 2004 Timing of Onset of Cerebral Edema in DKA
- 12. CALCULATIONS SERUM OSMOLALITY: 2[NA+K]+ (GLUCOSE/18) + BUN/2.8 SERUM NA: CORRECTED NA = MEASURED NA + (1.6)(GLUCOSE - 100)/100 ANION GAP: [NA] – ([CL]+[HCO3]) NORMALLY 12+/-2 MMOL/L
- 13. TREATMENT • Consider ICU admission for closer monitoring if: • Severe DKA (pH < 7.1 or < 7.2 in young child) • Altered level of consciousness • Under age of 5 years • Increased risk for cerebral edema • Caution with meds that may alter mental status
- 14. TREATMENT Monitoring • Management requires close attention to detail • Use a flowsheet to track vital signs labs, rates of insulin, fluids, dextrose • Neurological status • consider neuro checks q 1 hr • How does the patient look TO YOU? • Assess, reassess and then assess again
- 15. FLUID THERAPY FOR DKA • Assume 10-15% dehydration • Begin with a 10-20 ml/kg bolus of NS • Replace calculated deficit evenly over 36-48 hours • Do not exceed 40ml’s/kg in the initial 4 hours, or 4 L/m squared in 24 hours
- 16. DKA - FLUIDS • START BY ½ NS • K supplementation 20mEq/L K Acetate + 20mEq/L K Phosphate • Ionized calcium is low, phosphorous should not be given • early replacement and frequent monitoring • Bicarbonate therapy is rarely, if ever, indicated
- 17. INSULIN THERAPY FOR DKA • IV infusion with basal rate 0.1 U/kg/hr • No initial insulin bolus – it will decrease time to correction of the glucose, but does not alter the time to correction of acidosis It may decrease the serum osmolality more rapidly than desirable • Ideal glucose decline is about 100 mg%/hr • Continue insulin until urinary (blood) ketones are cleared
- 18. POTASSIUM • Add potassium when K< 5 and with urination • K >5.5 – no potassium in IVF • K 4.5 – 5.5 – 20 meq/L K+ • K <4.5 – 40 meq/L K+
- 19. USE OF BICARBONATE IN DKA • Bicarbonate should be used only when there is severe depression of the circulatory system or cellular metabolism... • Not recommended unless pH <7.0, not even then, unless above true
- 20. TREATMENT OF CEREBRAL EDEMA • Mannitol: 1 gram/ kg IV over 30 minutes • Elevate the head of the bed • Decrease IVF rate and insulin infusion rate • Pediatric ICU management • Do not delay treatment until radiographic evidence
- 21. SUCCESSFUL MANAGEMENT • Careful attention to detail • Careful record keeping • A detailed flow chart is essential • Following the data recorded is also essential • Repeated examination of the patient
- 22. THANK YOU