Pediatric DKA

[See Adult DKA]
  • NO INSULIN BOLUS

  • NO HCO3 regardless of pH

Initial Orders:
1.  NPO, CBC, CMP, ABG, Serum Ketones, UA w/ C+S, Blood Culture, CE & EKG, Amylase, Lipase CXR, Head CT ?
     NOTE: Ketones found in high ratio (1:36) means worse DKA
2.  CBG & K+  q2h
3.  NS 20 cc/kg Bolus x1, Then Maintenance x 1.5 (see below or See Calc.)
4.  Add K+ after first void or when K Normal.
    - 1/2 NS + KCL 20 mEq/L maintenance 1.5 (Calculate)
5.  K+ will bottom out. (monitor q2h)
6.  Change to D10 1/2 NS when CBG is 250
7.  IV Insulin (Novolin R):
        - NO BOLUS of insulin
        - Continuous insulin (Novolin R) infusion at 0.05 to 0.1 units/kg/hr
8.  Monitor patient closely:
  • Urine Output
    • Normal : 1 - 2.4 L/Day -OR-  0.5 mL/kg/hr
      •  Oliguric < 30cc/hr
      • Monitor with Foley.
    • Remove ASAP to prevent CAUTI
  • Monitor serum osmolality.
9.  Consider ABX, find the infection.

 


Summary/Overview:

  Dx Criteria Resolution Criteria What to do next? How to start Insulin?
Glucose Elevated < 200 (for DKA)
< 300
for HHS
Transition to D5W 1/2 NS (Acidosis is still not resolved)
1 U/kg/day
      OR
TDD x 0.8
1/2 Bolus 1/3 with breakfast NovoLOG
1/3 with lunch
1/3 with dinner
1/2 Basal 1/2 in AM Levemir
1/2 in PM
Anion Gap:  > 12   12 Can START SQ Insulin (overlap w/ IV x2hr).
Advance diet when Gap Normalized
HCO3:  < 15 15  
pH: < 7.30 >7.30  
Symptoms Nausea/ Vomiting Ability to eat (N/V resolved) Can Stop D5W
Advance diet when Gap Normalized
Mental Status Altered Normal  

 

Assessment of severity of diabetic ketoacidosis in children
  Mild Moderate Severe
Defining features
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum bicarbonate (mEq/L) 10-15 5-10 <5


NOTE: For initial insulin dose, the following formula is suggested:

  • TDD (Total Daily Dose) x 0.8 = ___ Units of estimated SQ insulin.
  • Administer first dose of basal insulin Levemir 2 hr prior to discontinuing IV infusion.
  • The maintenance fluids should either be discontinued or changed to remove Dextrose when pt transitions to regular diet.

 

Dx Criteria

Diagnostic criteria for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)

 

DKA

HHS

Mild Moderate Severe
Plasma Glucose >250 >250 >250 >600
Arterial PH 7.25 - 7.30 7.00 - 7.24 <7.00 >7.30
Serum HCO3 15-18 10 to <15 <10 >18
Urine Ketones* (+) (+) (+) (-) or small
Serum Ketones* (+) (+) (+) (-) or small
Effective Serum Osm. Variable Variable Variable >320
Anion gap Δ >10 >12 >12 Variable (<12)
Alteration in sensoria or mental obtundation Alert Alert
Drowsy
Stupor
Coma
Lethargy
Stupor
Coma
 

 

Assessment of severity of diabetic ketoacidosis in children
  Mild Moderate Severe
Defining features
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum bicarbonate (mEq/L) 10-15 5-10 <5

 

Resolution Criteria

Glucose: < 200 (for DKA), < 300 for HHS Transition to D5W 1/2 NS
Anion Gap: 12 Can START SQ Insulin (overlap w/ IV x2hr).
Advance diet when Gap Normalized
HCO3: 15  
pH: >7.30  
Ability to eat (No N/V) Can Stop D5W
Advance diet when Gap Normalized
Normal Mental Status  

NOTE: For initial insulin dose, the following formula is suggested:

  • TDD (Total Daily Dose) x 0.8 = ___ Units of estimated SQ insulin.
  • Administer first dose of basal insulin Levemir 2 hr prior to discontinuing IV infusion.
  • The maintenance fluids should either be discontinued or changed to remove Dextrose when pt transitions to regular diet.

 

Clinical Features

Clinical features
DKA usually evolves rapidly over a 24-hour period.
Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation. The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, and weight loss.
As hyperglycemia worsens, neurologic symptoms appear, and may progress to include lethargy, focal deficits, obtundation, seizure, and coma.
Common causes of DKA include: infection; noncompliance, inappropriate adjustment, or cessation of insulin; new onset diabetes mellitus; and myocardial ischemia.

 

Evaluation & Lab Findings

Evaluation and laboratory findings
Assess vital signs, cardiorespiratory status, and mental status.
Assess volume status: vital signs, skin turgor, mucosa, urine output.
Obtain the following studies: serum glucose, urinalysis and urine ketones, serum electrolytes, BUN and creatinine, plasma osmolality, mixed venous blood gas, electrocardiogram; add serum ketones if urine ketones present.
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, an elevated anion gap metabolic acidosis, and ketonemia. Dehydration and potassium deficits are often severe.
Serum glucose is usually > 250 mg/dL (13.9 mmol/L) and < 800 mg/dL (44.4 mmol/L). In certain instances (eg, insulin given prior to ED arrival), the glucose may be only mildly elevated.
Additional testing is obtained based on clinical circumstances and may include: blood or urine cultures, lipase, chest x-ray.


Bedside evaluation of neurological state of children with diabetic ketoacidosis (DKA)
Major criteria
Altered mentation/fluctuating level of consciousness
Sustained heart rate deceleration (decline of more than 20 beats per minute) not attributable to improved intravascular volume or sleep state
Age-inappropriate incontinence
Minor criteria
Vomiting
Headache
Lethargy or being not easily aroused from sleep
Diastolic blood pressure >90 mmHg
Age <5 years
Diagnostic criteria
Abnormal motor or verbal response to pain
Decorticate or decerebrate posture
Cranial nerve palsy (especially III, IV, and VI)
Abnormal neurogenic respiratory pattern (eg, grunting, tachypnea, Cheyne-Stokes respiration, apneusis)

 

Glasgow coma scale and pediatric Glasgow coma scale

Sign Glasgow Coma Scale Pediatric Glasgow Coma Scale Score
Eye opening Spontaneous Spontaneous 4
To command To sound 3
To pain To pain 2
None None 1
Verbal response Oriented Age-appropriate vocalization, smile, or orientation to sound, interacts (coos, babbles), follows objects 5
Confused, disoriented Cries, irritable 4
Inappropriate words Cries to pain 3
Incomprehensible sounds Moans to pain 2
None None 1
Motor response Obeys commands Spontaneous movements (obeys verbal command) 6
Localizes pain Withdraws to touch (localizes pain) 5
Withdraws Withdraws to pain 4
Abnormal flexion to pain Abnormal flexion to pain (decorticate posture) 3
Abnormal extension to pain Abnormal extension to pain (decerebrate posture) 2
None None 1
Best total score 15

 

Assessment of severity of diabetic ketoacidosis in children
  Mild Moderate Severe
Defining features
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum bicarbonate (mEq/L) 10-15 5-10 <5

 

Management (Pedi)

Rapid overview of the initial evaluation and treatment of moderate to severe diabetic ketoacidosis (DKA) in children and adolescents
Definition of diabetic ketoacidosis (DKA): hyperglycemia (blood glucose of ≥200 mg/dL (11 mmol/L) and metabolic acidosis (venous pH <7.30 and/or serum bicarbonate <15 meq/L), resulting in hyperosmolality and volume depletion.
Evaluation: assessment of severity
  • Degree of dehydration - Patients with DKA are usually more dehydrated than suggested by the clinical examination. For moderate to severe DKA, initial fluid management is based on assuming 7 to 10 percent fluid deficit at presentation.
  • Initial laboratory testing should include, at a minimum: serum testing for glucose, electrolytes, creatinine and urea nitrogen, blood gases, hematocrit, hemoglobin A1C, venous pH, and routine urinalysis.
  • Neurologic status: Patients with abnormal mental status may have cerebral edema (see complications below).
Management
Fluids:
  • Initial bolus of 10 mL/kg x1 of an NS or LR given over one hour. A second bolus may be infused over the next hour for patients with compromised circulation.
  • 20 mL/kg boluses may be used for the patient with DKA in shock. Hypovolemic shock is a rare occurrence in DKA, and should prompt evaluation for other causes, such as sepsis.
  • Following initial fluid resuscitation, replace deficit over the next 48 hours. This fluid should be given no more rapidly than 1.5 to 2 times the maintenance rate during the first 24 hours. Use an isotonic solution (NS or LR + 40 mEq KCL) for the first 4 to 6 hours, then switch to 1/2 NS.
  • Urinary losses should not be replaced.

Calculator = Pedi DKA Calculator

Electrolytes
  • Sodium: Serum sodium levels are generally low and should rise as fluid deficit, hyperglycemia, and acidosis are corrected. Failure of the serum sodium to rise appropriately may be an early sign that the patient is at risk for cerebral edema.
  • Potassium: Regardless of the initial measured level of serum potassium, patients with DKA have a total body potassium deficit. Therapy with fluids and insulin will lower potassium. Therefore, potassium should be immediately added to intravenous fluid for patients who are hypokalemic. If the patient is normokalemic, potassium replacement should begin with the start of insulin therapy (eg, adding 40 meq/L of potassium to the IV solution). For patients who are hyperkalemic, potassium replacement should be initiated when the serum potassium falls to normal.
Insulin:
  • Do not give an initial bolus of insulin.
  • After the initial fluid bolus, begin a continuous insulin (Novolin R) infusion at 0.05 to 0.1 units/kg/hr. Mix 50 units of Regular insulin in 50 mL normal saline (such that 1 mL of the infusion provides 1 unit of insulin).
  • STOP insulin drip when pH > 7.30 & HCO3 > 18
     
Glucose: Blood glucose falls rapidly during the initial volume expansion, but after that should not fall faster than 90 mg/dL (5 mmol/L) per hour.
  • Add 5% dextrose solution when blood glucose falls to 300 mg/dL (17 mmol/L).
  • Add dextrose sooner if level is dropping too quickly.
  • It may be necessary to use a higher concentration (10 to 12.5% dextrose) to prevent hypoglycemia while continuing to infuse insulin to correct metabolic acidosis.
Monitoring
  • Record hourly vital signs and neurologic status, as well as fluid intake (intravenous and oral) and losses.
  • Measure blood glucose, electrolytes, and venous pH hourly for the first three to four hours. Continue to monitor blood glucose hourly. Electrolytes and venous pH may subsequently be measured every two hours.
Complications
Cerebral Edema:
  • The risk for cerebral edema is increased with young age, and with greater degree of acidosis or dehydration at presentation.
  • Monitor neurologic status carefully.
  • Treatment:
    • Protect airway if needed, HOB 30 degree
    • Consider Mannitol 0.25-1 g/kg as soon as cerebral edema is suspected.
    • Consider 3% hypertonic saline bolus 10cc/kg
    • Reduce rate of fluid to 0.5 x maintenance rate
    • Support oxygenation and ventilation.
    • Neurosurgery Consult, ICU Admit
  • Venous thrombosis: Avoid placing a central line.
  • Aspiration (as the result of altered mental status and vomiting): Consider placing nasogastric tube in children with these symptoms.
  • Cardiac arrhythmia (as the result of hypo or hyperkalemia)
  • Pancreatic enzyme elevations are common in DKA and do not generally reflect pancreatitis. The laboratory abnormality generally corrects with treatment of the DKA.


 
Assessment of severity of diabetic ketoacidosis in children
  Mild Moderate Severe
Defining features
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum bicarbonate (mEq/L) 10-15 5-10 <5

Source: uptodate
 


Monitoring

Monitoring of children during treatment for diabetic ketoacidosis
Parameter Frequency Comments
Vital signs Hourly Decreased resting heart rate or increased blood pressure suggest possible cerebral edema.
Fluid input and output Hourly Include oral fluids.
Neurological status At least hourly

Assess with Glasgow coma scale.

Assess for headache, decreased heart rate, age-inappropriate incontinence, as well as vomiting, restlessness, irritability, or drowsiness (refer to table describing the neurological evaluation in DKA).
Blood glucose Hourly Use a point-of-care meter, but cross-check with laboratory tests, to ensure correlation.
Blood beta-hydroxybutyrate q2h

Perform if test is available.

Resolution of DKA is indicated by beta-hydroxybutyrate ≤1 mmol/L (10.4 mg/dL) on two successive occasions.
CBC, BMP
Ca, Mg, Phos
ABG
At least q2h

Timing of initiating potassium replacement depends on initial serum potassium level (see topic text).

Calculate the anion gap:
  • Anion gap = Sodium – (chloride + bicarbonate)
  • Normal anion gap = 12±2; indicates resolution of DKA
Calculate the corrected sodium concentration:
  • Corrected Sodium = measured sodium + [ΔSG ÷ 42]
  • Where ΔSG is the increment above normal in serum glucose concentration, in mg/dL.
ECG monitoring Continuous, if available Initiate monitoring for patients with severe DKA or abnormal serum potassium concentrations. Monitor for T-wave flattening and inversion, or prolonged PR interval, which indicate hypokalemia.
 

Insulin Dose

(0.5-0.8 U/kg/day)
1 U/kg/day
      OR
TDD x 0.8
1/2 Bolus 1/3 with breakfast
1/3 with lunch
1/3 with dinner
1/2 Basal 1/2 in AM
1/2 in PM

 


 

Admit Orders: DKA

1. Admit to:  ICU
2. Diagnosis:
 Diabetic ketoacidosis
3. Condition:
4. Vital Signs:
 q1-4h. Call physician if BP >160/90, <90/60; P >140, <50; R >30, <10; T >38.5°C; or urine output <20 mL/hr for more than 2 hours.
5. Activity:
 Bed rest with bedside commode.
6. Nursing:
 Inputs and outputs. Foley to closed drainage. Record labs on flow sheet.
7. Diet:
 NPO for 12 hours, then clear liquids as tolerated.
8. IV Fluids:

  500 mL NS IV boluses; report until blood pressure is >100/60 mmHg, then change to 0.45% saline at 125-150 cc/hr; keep urine output >30-60 mL/h.
  Add KCL when serum potassium is <5.0 mEq/L.
  Concentration.......20-40 mEq KCL/L
  Use K phosphate, 20-40 mEq/L, in place of KCL if hypophosphatemic.
  Change to 5% dextrose in 0.45% saline with 20-40 mEq KCL/liter when blood glucose is 250-300 mg/dL.


9. Special Medications:

  -Oxygen at 2 L/min by NC.
  -Insulin regular (Humulin) 7-10 U/h IV infusion (0.1 U/kg/h); 50 U in 250 mL of 0.9% saline; flush IV tubing with 20 mL of insulin solution. Titrate. Adjust insulin to decrease serum glucose by 100 mg/dL per hour.
  -When bicarbonate level is >16 mEq/L and the anion gap is <16 mEq/L, decrease insulin infusion rate by half.
  -Start subcutaneous insulin when the anion gap has cleared; discontinue insulin infusion 1-2h after subcutaneous dose.


10. Symptomatic Medications:

  -Famotidine (Pepcid) 20 mg IV q12h.
  -Docusate sodium (Colace) 100 mg PO qhs.
  -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.
  -Zofran 4 mg IV q4h

11. Extras: Portable CXR, ECG.
12. Labs:
 Fingerstick glucose q1-2h.  CBC, CMP, then BMP q4-6h. HCO3, Mg, phosphate, hemoglobin A1c; Anion gap, Serum lactate, Serum amylase/lipase, Serum Osmolality, Blood/Urine/Sputum cultures, Cardiac enzymes, ABG. UA, beta-HCG, serum ketones, Acetones.