Management of Diabetic Ketoacidosis in the PICU
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Transcript Management of Diabetic Ketoacidosis in the PICU
Management of
Diabetic Ketoacidosis
in the PICU
PICU Resident Lecture Series
DKA - A common PICU diagnosis
Incidence 4.6 – 8 per 1000 person years
among people with diabetes
Pediatric mortality rate is 1-2%
DKA causes profound dehydration
Hyperglycemia leads to osmotic diuresis
Often 10-15% down from baseline weight
Profound urinary free water and electrolyte
loss
Free water follows glucose into urine
Electrolytes follow free water into urine
Electrolyte abnormalities
Pseudo-hyponatremia with hyperglycemia
Profound total-body K+ depletion
Sodium should rise with correction of glucose
Urinary loss, decreased intake, emesis
Initial K+ may be high due to acidosis, low insulin
Aggressive K+ replacement necessary to prevent
arrhythmias
Phosphate, magnesium, calcium require
replacement
Initial DKA management - ED
Resuscitation aimed at shock reversal
Begin with 10-20 mL/kg NS bolus, may repeat if
signs of shock persist
Bolus fluids only necessary if signs of shock
present
Avoid overly-aggressive fluid resuscitation
Concern for inciting cerebral edema, though no
clear data
Initial DKA management - ED
NEVER give bicarbonate
Increases risk of cerebral edema
Begin insulin infusion at 0.1 units/kg/hr
Should be initiated prior to leaving ED
SQ or bolus insulin not indicated
Pre-PICU arrival
Order several bags of dextrose-containing
and non-dextrose-containing IVF pre-PICU
arrival
Often takes pharmacy 1 hour to custom-make
IVF
No dextrose-containing fluids stocked in PICU
Fluid Management - PICU
3 components to replacement fluids
Deficit (often 10-15% total body water deficit)
Ongoing losses (polyuria, emesis)
Maintenance
Possible to calculate the above, or give:
1.5X maintenance if moderately dehydrated
2X maintenance if severely dehydrated
Initial IVF
Isotonic fluid with potassium
NS + 20 mEq/L KCl + 20 mEq/L KPhos
Start with 40 mEq/L of potassium if K+ < 5
K+ often split between KCl and KPhos to avoid
hyperchloremic metabolic acidosis
NS preferred to help prevent cerebral edema
Adding dextrose
Add dextrose to IVF when glucose < 300
2 bag system allows titration of dextrose
based on glucose
Bag 1: NS + 20 KCl + 20 KPhos
Bag 2: D10 NS + 20 KCl + 20 KPhos
Titrating dextrose
2 bag system example: Total IVF rate =
160 mL/hr
Fingerstick glucose = 280
Bag 1: NS + 20 KCl + 20 KPhos @ 120 mL/hr
Bag 2: D10 NS + 20 KCl + 20 KPhos @ 40 mL/hr
Fluids “Y” together, dextrose concentration = D2.5
Titrating dextrose
2 bag system example: Total IVF rate =
160 mL/hr
Fingerstick glucose = 180
Bag 1: NS + 20 KCl + 20 KPhos @ 40 mL/hr
Bag 2: D10 NS + 20 KCl + 20 KPhos @ 120 mL/hr
Fluids “Y” together, dextrose concentration = D7.5
Frequent lab monitoring is essential in
DKA
Glucose q1 hour
Chem 10 , VBG q4 hours
To correct venous pH to arterial pH, add 0.04
Serial UAs to monitor for resolution of
glucosuria and ketonuria
DKA vs. Hyperglycemic
Hyperosmolar Syndrome (HHS)
HHS more likely in older, obese patients
with Type II DM
Lab features of HHS
More severe hyperglycemia than DKA
Less severe or absent acidosis
Trace or absent ketones in urine
Can have normal serum bicarb
Serum osmolality > 320
Importance of Insulin
Insulin is the only therapy that corrects the
underlying pathophysiology in DKA
Increase dextrose as necessary to continue
insulin infusion at 0.1 units/kg/hr
Do NOT titrate insulin drip
Transitioning to SQ insulin
May consider transition when:
Bicarb > 18, pH > 7.3, AG <12, GCS 15, emesis
resolved
How to transition – order of events:
Fingerstick glucose pre-meal eat meal give
SQ insulin stop drip
May re-check VBG post-meal to ensure that
acidosis has not recurred
Complications of DKA
Cerebral Edema
Vasogenic vs. cytotoxic, unclear etiology
Risk factors:
Age <5 years
High BUN (severe dehydration)
Severity of acidosis
Bicarbonate administration
New-diagnosis diabetes
Na levels don’t rise as expected with treatment
Cerebral Edema
Hourly neuro / pupillary checks
Mannitol 0.5 g/kg at bedside
Consider 3% NaCl bolus 3-5 mL/kg if Na drops
with therapy
Stat head CT for any concerning mental status
changes
Give mannitol prior to going to CT!
If CT reveals cerebral edema and GCS is <8,
consult neurosurgery for ICP monitoring
Complications of DKA
Thrombosis
Dehydration, low flow state
Avoid central lines if possible
ARDS
Rapid fluid resuscitation with low albumin at
baseline capillary leak, pulmonary edema
Rare complication in pediatric DKA
Complications of DKA
Hyperchloremic metabolic acidosis
Hypoglycemia
May check urine for ketones if unsure whether DKA has
resolved
Rare with appropriate dextrose titration
Hypokalemia
Can lead to fatal arrhythmias
K+ must be repleted aggressively
10 Tips for Managing DKA in PICU
2 large-bore PIVs
Frequent lab
monitoring
Hourly neuro checks
Watch for falling
sodium
Correct hypokalemia
aggressively
NEVER give bicarb
Do NOT titrate insulin
drip
Mannitol to bedside
Order IVF pre-PICU
arrival
Search for underlying
cause (infection, noncompliance, etc.)