Hyperglycemia, Diabetes and Diabetic Ketoacidosis - DKA (1 - 18 years)



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Hyperglycemia, Diabetes and Diabetic Ketoacidosis - DKA (1 - 18 years)

Consult endocrinology

Blood glucose prior to insulin drip (if BG < 200 start dextrose with insulin drip)

Consult endocrinology to determine phosphorous supplementation

ECG

< 5 years or extreme insulin sensitivity?

Spike line with insulin, allow to saturate, then waste fluid in line, and re-prime prior to infusion

Regular insulin infusion

Spike line with insulin, allow to saturate, then waste fluid in line, and re-prime prior to infusion

Regular insulin infusion

Cerebral Edema Risk Tool

(Positive if: 1 diagnostic criterion, 2 major, or 1 major and 2 minor criterion)

Variable

Diagnostic criteria

  • Abnormal motor or verbal response to pain
  • Decorticate or decerebrate posturing
  • Cranial Nerve Palsy (III, IV, VI), double vision
  • Abnormal respiratory pattern (e.g. grunting, central hypoventilation, Cheyne-Stokes, apnea)

Major criteria

  • Altered or fluctuating level of consciousness
  • Sustained heart rate deceleration (more than 20 beats/min) not attributable to improved intravascular volume or sleep state
  • Age inappropriate incontinence

Minor criteria

  • Vomiting
  • Headache
  • Lethargy
  • Diastolic BP > 90 mmHg
  • Age < 5 years

Cerebral edema commonly develops 4-12 hours into treatment, but may occur at any time.

Inclusion Criteria
  • History of type one diabetes with hyperglycemia (BG > 200 x2)
  • Undiagnosed hyperglycemia (BG > 200 x2 OR BG > 200 x1 with symptoms)
Exclusion Criteria
  • Other metabolic, treatment or diagnosis to explain hyperglycemia
  • Suspected hyperglycemic hyperosmolar syndrome (HHS)
  • IV insulin (hyperkalemia, TPN, etc.)

Hold potassium in fluid until potassium < 5.5, repeat potassium in 1 hour

ECG

Repeat serum potassium after infusion complete

ECG
Potassium infustion

Glucose by Meter, POC

Fluid Calculation

Step 1: Determine 1.5 times maintenance fluid rate (ml/hr)

  • 4 ml/hr for the first 10 kg of weight
  • 2 ml/hr for the next 10 kg of weight
  • 1 ml/hr for the remainder of weight
  • 1.5 x total
  • Example 1.5x maintenance: 35 kg patient = ((4 ml/hr x 10 kg) + (2 ml/hr x 10 kg) + (1 ml/hr x 15 kg)) x 1.5 = 112.5 ml/hr

Step 2: Determine infusion rates of Bag 1 and Bag 2 of fluids based on Q1 hour blood glucose

Blood Glucose

Bag 1: Normal Saline

Bag 2: D10 Normal Saline

If > 300

1.5x maintenance x 100%

0%

If 251-300

1.5x maintenance x 75%

1.5x maintenance x 25%

If 201-250

1.5x maintenance x 50%

1.5x maintenance x 50%

If 151-200

1.5x maintenance x 25%

1.5x maintenance x 75%

If <= 150

Stop infusion and notify endocrinology

1.5x maintenance x 100%, order D12.5 NS to have ready

If < 100

1.5x maintenance x 100% of D12.5 NS

If < 70

  • Stop insulin drip
  • Try not to stop for more than 15 min
  • Notify endocrinology
  • Rate (ml/hr) x 100% of D12.5 NS
  • Consider bolus glucose

Previous diagnosis of diabetes?

Meets discharge criteria?

Add 40 mEql/L to fluids

Phosphorous < 1?

Bicarbonate > 14 and clinically asymptomatic (no vomiting, etc.)?

Consult endocrinology for potential subcutaneous treatment, admit

Potassium < 3.5

Fever or signs of infection?

Glucose by Meter, POC

Meets DKA criteria?

Admit to Floor

Discharge, follow with PMD and endocrinology

  • Consult endocrinology, notify ICU, admit to ICU
  • VBG with lytes STAT if signs of clinical status worsening
  • Cerebral edema assessment Q1 hour for 24 hours

Basic Metabolic Panel, Serum

Close monitoring for risk of cerebral edema

NS Bolus

Potassium > 5.5 or no urine in 12 hours?

Insulin drip

  • DKA goal: Start insulin drip within 2 hours of presentation, but not until AFTER initial fluid replacement is complete (e.g. 10mL/kg bolus over 1hr)
  • The insulin drip should NOT be routinely titrated during DKA resuscitation. Instead, additional dextrose infusions should be used to stabilize blood glucose levels.

Admit to ICU

Initial stabilization

  • Assess airway and assist ventilation as necessary
  • Avoid intubation unless the patient is hypoventilating or if airway reflexes are lost
  • Assess for severe electrolyte abnormalities (e.g. hypoglycemia, hyponatremia, relative hypernatremia, etc.)
  • Reduce fluid administration to 1/3rd maintenance if hemodynamics allow it
  • If patient requires fluid resuscitation to maintain perfusion, this takes priority

Treatments

  • 1st line: Mannitol 1 g/kg IV over 20 min (repeat if no response within 30 min)
  • 2nd line: Hypertonic (3%) saline 5 ml/kg bolus followed by continious infusion to target serum sodium of 150-160 mEq/L (requires central line)

After stabilization

  • Consult endocrinology
  • CT brain without contrast
  • Admit to ICU

CT Head WO Contrast

Intravascular dehydration assessment

Clinical concern for cerebral edema?

DKA diagnosis (requires all criteria)

  • Hyperglycemia > 200 mg/dL
  • Ketonemia (BOHB > 1 mmol/L) OR Ketouria
  • pH < 7.3 OR HCO3 < 15 mEq/L

Human insluin antibody, Serum
Anti-GAD 65 antibody, Serum
ICA 512 antibody, Serum
Hemoglobin A1C, Serum

Glucose by Meter, POC
ISTAT Venous Blood Gas and Lactate, Serum
Magnesium, Serum
Phosphorus, Serum
Basic Metabolic Panel, Serum
Diet NPO
Can start bolus at 20mL/kg.

NS Bolus

Treat appropriately or consult endocirnology



DKA

HHS

Onset

Sudden (hours to days)

Insidious (days, weeks)

Primary effects

Type 1

Type 2

Clinical findings

  • N/V, weight loss, polyuria/plolydipsia, dehydration, abdominal pain, fatigue, headache/confusion
  • Ketoacidosis: air hunger, Kussmaul breathing, acetone breath odor
  • No ketosis, no breath odor, rapid and shallow respirations, usually mild N/V

Laboratory findings

  • Glucose > 200 mg/dL
  • Ketones: moderate to strongly positive
  • pH < 7.3
  • Osmolarity < 320 mOsm/L
  • Bicarbonate < 15 mEq/L
  • BHOB > 3 mmol/L
  • Glucose > 600 mg/dL
  • Ketones: normal or mildly elevated
  • pH normal (unless lactic acidoses develops)
  • Osmolarity > 320 mOsm/L
  • Bicarbonate > 15 mEq/L

Discharge criteria

  • Urgent follow up with endocrinology scheduled
  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Electrolyte considerations in DKA

Sodium

  • Use the corrected NA to guide therapy
  • Corrected Na = measured Na + [(serum glucose as mg/dL - 100)/100] x 1.6

Potassium

  • Maintenance fluids should be determined after serum potassium is resulted.

Phosphate and Calcium

  • If severe hypocalcemia present - obtain ECG
  • Phosphate replacement may induce hypocalcemia
  • No proven benefit of phosphate replacement in DKA, but can be given safely
  • Severe hypophosphatemia + unexplained weakness should be treated.
  • Administration of phosphate and calcium supplements in the same IV tubing may cause precipitation, complications and death.

Magnesium

  • Replacement of magnesium is not routinely recommended in DKA

Bicarbonate

  • Bicarbonate SHOULD NOT be routinely used in DKA treatment. Controlled trials have shown no benefit from bicarbonate use and possible harm.
  • If there is acidosis thought be be affecting cardiac contractility, bicarbonate use may be considered

Empiric antibiotics as necessary

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum