Type I Diabetes, DKA



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Type I Diabetes, DKA
Inclusion Criteria
  • Hyperglycemia (blood glucose > 200 mg/dL
  • Acidosis (venous pH < 7.3 or serum bicarbonate < 15 mmol/L)
  • Ketonemia/Ketonuria
Exclusion Criteria
  • None

Pathophysiology: Insulin deficiency precipitated by stress, infection, or non-compliance leads to increase in counterregulatory hormones resulting in lipolysis, proteolysis, glycogenolysis, and decrease in glucose utilization. Leads to ketogenesis and hyperglycemia.

ONGOING LABS:

  • q1h glucose while on Insulin infusion
  • q2h electrolytes (BMP, Ca, Mg, Phos) + VBG
  • If serum glucose < 100, increase IVF to 2x maintenance. If this does not increase serum glucose < 100, reduce insulin drip to 0.08 units/kg/hr, followed by 0.05 units/kg/hr as needed
  • Can discontinue insulin infusion when anion gap is normal, HCO3 > 17, able to tolerate PO

Treatment

References:

Agus MS, Wolfsdorf JI. Diabetic Ketoacidosis in Children. Pediatr Clin North Am 2005;52(4):1147-63, ix.

Glaser NS, et al. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatric Diabetes 2013; 14: 435–446.

INSULIN

  • 0.1 units/kg/hour (avoid any lower concentrations unless child is < 12 months)

** NEVER BOLUS WITH INSULIN **

Initial Labs and Assessment:

  • Vital signs and assess for shock (tachycardia, hypotension, poor perfusion)
  • Neurologic assessment (signs of cerebral edema include confusion, lethargy, headache, slowing heart rate, decrease O2 saturation)
  • IV access
  • Labs - POC glucose, VBG, BMP, Ca, Mg, Phos, HgbA1C, UA, CBC, blood culture (if febrile), serum ketones (optional), HCG (as needed)

Symptoms:

  • +/- polyuria, polydypsia, polyphagia, weight loss in preceding weeks
  • nausea and/or vomiting
  • abdominal pain
  • altered mental status (if severe, lethargy/coma)
  • hyperventilation and deep respiratory pattern (Kussmaul)

FLUIDS

  1. Initial fluid resuscitation - 10 mL/kg NS over 1 hour, repeat as needed. Do not rapidly bolus unless evidence of shock.
  2. Maintenance fluids - start IVFs (NS or LR) at 1.5x maintenance. Continue until off Insulin
  3. Initiate 2 bag system - (Option 1: D10NS + 20 mEq/L KPhos + 20 mEq/L KCl, Option 2: D10NS + 20 mEq/L KPhos + 20 mEq/L KAcetate, Option 3: NS + 20 mEq/L KPhos + 20 mEq.=/L KCl (or KAcetate)
    1. When serum glucose > 250, 100% NS IVF
    2. When serum glucose 150-250, 50% D10 IVF + 50% NS IVF
    3. When serum glucose < 150, 100% D10 NS IVF

** Do not add potassium to IVF until patient has voided and serum K > 5.5 (patients are total body depleted of K, but acidosis causes extracellular shift of potassium, which can lead to arrhythmias) **

** NEVER BOLUS BICARBONATE (increased risk of cerebral edema and herniation) **