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Pediatric DKA Management: Case Study of a 6-Year-Old Child

A case study of a 6-year-old child with rapid breathing and weight of 20 kg, presenting to the emergency room. Learn about the diagnosis and management of diabetic ketoacidosis (DKA) in pediatric patients.

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Pediatric DKA Management: Case Study of a 6-Year-Old Child

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  1. IN THE NAME OF GOD

  2. DKA Management M. Hashemipour Pediatric Endocrinologist Isfahan university of medical sciences بهمن 1395

  3. Case study • کودک 6 ساله ای با وزن 20 کیلو گرم با تنفس تند به اورژانس وارد شده • در بدو ورود • شما چیست؟ • PH=6.9 ,CO3H= 5 • NA=135 • K=5.5 • BS=624

  4. DKA Defined • Plasma glucose >200 mg/dl • Arterial pH <7.30 • Bicarbonate level <15 mEq/l • ketonemia>3 mmol/L • Moderate ketonuria Pediatr Clin N Am 2005 Pediatric Diabetes 2014 ISPAD clinical practice consensus guidelines 2014

  5. Pediatric Diabetes 2014 Endocrinology and Metabolism clinics of north America 2006 ISPAD clinical practice consensus guidelines 2014

  6. How to Treat DKA

  7. How to Assess severity of Dehydration • Prolonged capillary refill time • Abnormal skin turgor • Abnormal respiratory pattern • sunken eyes, absent tears • weak pulses, and cool extremities • level of consciousness Pediatric Diabetes 2014

  8. Lab Measurement • Blood gases • Blood or urine ketones • serum electrolytes • Full blood count • Blood urea nitrogen, creatinine • Serum osmolality • ECG for baseline evaluation of potassium • Pediatric Diabetes 2014

  9. The goals of therapy • improvement of circulatory volume and tissue perfusion • Correct acidosis and reverse ketosis • slowly Reduction of serum glucose and plasma osmolarity

  10. The goals of therapy • identification and prompt treatment of comorbid precipitating causes. • correction of electrolyte imbalance • Improved glomerular filtration • increase clearance of glucose and ketones from the blood

  11. کودک 6 ساله ای با وزن 20 کیلو گرم با تنفس تند به اورژانس وارد شده • در بدو ورود • PH=6.9 ,CO3H= 5 • NA=135 • K=5.5 • BS=624

  12. چه درجه ای از DKA مطرح است • درمان را چگونه آغاز می کنید؟ • کنترل قند خون با انسولین چگونه است؟ • قند خون در چه سطحی باید حفظ شود؟ • میزان ونوع مایع دریافتی به بیمار چگونه خواهد بود؟

  13. Severe DKA

  14. Step1 • Fluid Therapy

  15. Step2 • Evaluation of predisposing factors

  16. Step3 • Adding K to IV fluid after urination

  17. Step4 • Insulin therapy

  18. Step5 • Bicarbonate therapy??????

  19. Step6 Monitoring • Vital sign • Level of consciousness

  20. Volume Expansion Shock? • 0.9% NaCl 20 ml/kg bolus. • Repeat if necessary No Shock • 0.9 % NaCl 10 ml/kg /h over 1-2 hours

  21. Volume Expansion Repeated if • Shock • Hypotension • Delay capillary refilling • Decrease tissue perfusion Not exceed 30 ml/kg

  22. Fluid therapy • Maintenance • Deficit • Abnormal ongoing loss

  23. Fluid deficit • Grade of dehydration 5% to 10% • In mild to moderately DKA, fluid deficits 30 to 50 mL/kg. • In moderate to severe DKA, fluid deficits 50 to 100mL/kg.

  24. Fluid therapy • To replace the estimated fluid deficit evenly Over36- 48 h. ISPAD clinical practice consensus guidelines 2014

  25. Milwaukee formula • Iv rate= 85cc/kg+maintenance- bolus÷ 23hr • Iv rate= 85* 20 +1500-300 ÷ 23hr • Iv rate= 126 cc /hr Nelson 2014

  26. Second Method • First day 1.5-2 times the 24 h maintenance requirements • with isotonic solution 0.9% saline,Ringer’s lactate for at least 4–6 h • Then half salin 0.45% salin • Pediatric Diabetes 2014 • ISPAD clinical practice consensus guidelines 2014

  27. second Method • WT= 20kg • Maintenance =1500cc • Fluid requirement for DKA=2*1500 • Fluid requirement for DKA=1.5*1500

  28. Pediatric Fluid therapy • Usually 1.5 times the 24 h maintenance requirements • Urinary losses should not be added to the calculation of replacement fluids Pediatrics 2004;113;133-140 Pediatric Diabetes 2014 ISPAD clinical practice consensus guidelines 2014

  29. Third method Begin with 0.9% NaCl. • Weight (kg) Infusion rate (ml/kg/h) • 4 – 9 6 • 10 – 19 5 • 20 – 39 4 • 40 - 59 3.5 • 60 - 80 3 • ISPAD clinical practice consensus guidelines 2014

  30. Forth method • No transport available • ORS 5 ml/kg/h • Give . as fruit juice or coconut water if ORS is not available. • Give SC insulin 0.05 U/kg every 1-2 hours 0.025 U/kg if < 5 years ISPAD clinical practice consensus guidelines 2014

  31. Improved condition? • Decreasing blood glucose AND decreasing ketones in urine indicate resolving of acidosis

  32. ساعت 6 درمان قند خون بیمار 250 است نوع و میزان مایع 6 ساعت بعدی را بنویسید

  33. Second Method • Iv rate= 85cc/kg+maintenance- bolus÷ 23hr • Iv rate= 85* 20 +1500-300 ÷ 23hr • Iv rate= 126 cc /hr

  34. مایع 6 ساعت بعدی • 126*6 = 756 cc • دکستروز5% همراه با 75 میلی اکی والان سدیم درلیتر • در واقع در مایع فوق 56 میلی اکی والان سدیم باید باشد • بنابر این در مایع فوق 81 سی سی سدیم کلراید 20% می ریزیم • هر 1 سی سی سدیم کلراید 20% حاوی 3.2 میلی اکی والان سدیم است

  35. Fluid therapy • Dextrose 5% was added in 0.45% NS to the rehydrating solution once the blood glucose fell to200- 300 mg/dL Pediatr Crit Care Med 2004 Endocrinol Metab Clin N Am 2006 Pediatric Diabetes 2014 ISPAD clinical practice consensus guidelines 2014

  36. Glucose concentration during DKA • plasma glucose typically decreases At a rate of 40-90 mg /dl/h • Depending on the timing and amount of glucose administration

  37. When we adddextrose? • If blood glucose falls very rapidly >90 mg/dl/h) after initial fluid expansion • Consider adding glucose even before plasma glucose has decreased to 300 mg/dl

  38. When we adddextrose? Acidosis with BS 100-200mg/dl • Add%7.5 dextrose to solution • Insulin should be continue

  39. When we adddextrose? Acidosis with BS <100mg/dl • Add%10 dextrose to solution • Insulin should be continue

  40. When we discontinue intravenous fluids? . • Administration of intravenous fluids should be continued until acidosis is corrected and a patient can tolerate fluids and food. Pediatr Clin N Am 52 (2005) 1147– 1163

  41. Fluid therapy Maintain the blood glucose 100 and 200 mg/dL.

  42. When we added potassium? • At same time as insulin treatment • After urination • Pediatr Crit Care Med 2004 Vol. 5, No. 5

  43. Potassium • The plasma potassium concentration should be rechecked every 1 to 2 hours if the plasma concentration is outside the normal range.

  44. Potassium • potassium 40meq/li • k<3mEq/l insulin should be hold temporary • Give 0.5 -1mmol/kg/h iv and oral EndocrinolMetabClin N Am 35 (2006) 725–751

  45. K>5 meq/l Don’t give K till reversal of k<5meq/l

  46. Indication of Bicarbonate therapy • life-threatening hyperkalemia. • severe acidosis pH<6.9 • Hypotension • shock • Arrhythmia

  47. Bicarbonate Therapy After 2-3hours of hydration if • severe acidaemia • pH <7.0 or bicarbonate <5 mEq • A state of shock • it may be appropriate to use bicarbonate • Give 1meq/kg over 1 hour • ISPAD clinical practice consensus guidelines 2014

  48. Biochemical& Clinical monitoring • Critical Observations • Hourly blood glucose • Hourly fluid input & output • Neurological status at least hourly • Electrolytes 2 hourly after start of IV therapy • Monitor ECG for T-wave changes

  49. Biochemical& clinical monitoring • Repeated 2–4 h, or more frequently, as clinically indicated

  50. insulin therapy • Begin with 0.05–0.1 U/kg/h • 1–2 h after starting fluid replacement therapy

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