Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

1. Emergency CarePart 1: Managing Diabetic Ketoacidosis (DKA) Presentation title

2. Slide no 2 Programme Managing DKA 1 2 Treating and preventing hypoglycaemia 3 Surgery in children with diabetes

3. Diabetic Ketoacidosis Occurs when there is insufficient insulin action Commonly seen at diagnosis Is a life-threatening event Child should be transferred as soon as possible to the best available site of care with diabetes experience Initiate care at diagnosis Slide no 3

4. Type 1 Diabetes Increased urine Dehydration Thirst

5. DKA • Weight loss • Ketones • Nausea • Vomiting • Abdominal pain • Altered level of consciousness • Shock • Dehydration Liver Muscle Fat Ketones Weight loss

6. Clinical features Slide no 6

7. Managing DKA • Refer to best available site of care whenever possible • Need: • Appropriate nursing expertise (preferably a high level of care) • Laboratory support • Clinical expertise in management of DKA • Written guidelines should be available • Document and use the form Slide no 7

8. DKA monitoring form

9. DKA monitoring • DKA protocol available to the clinic

10. Principles of DKA management (1) Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 10

11. Principles of DKA Management (2) • Correction of shock or decreased peripheral circulation – quick phase • Correction of dehydration - slow phase Do not start insulin until the child has been adequately resuscitated, i.e. good perfusion and good circulation Slide no 11

12. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 12

13. Assessment • History and examination including: • Severity of dehydration. If uncertain about this, assume 10% dehydration in significant DKA • Level of consciousness • Determine weight • Determine glucose and ketones • Laboratory tests: blood glucose, urea and electrolytes, haemoglobin, white cell count, HbA1c Slide no 13

14. Resuscitation (1) Ensure appropriate life support (Airway, Breathing, Circulation, etc.) Give oxygen to children with impaired circulation and/or shock Set up a large IV cannula/intra-osseous access. Give fluid (saline or Ringers Lactate) at 10ml/kg over 30 minutes if in shock, otherwise over 60 min. Repeat boluses of 10 ml/kg until perfusion improves Slide no 14

15. Resuscitation (2) If no IV available, insert nasogastric tube or set up intraosseous or clysis infusion Give fluid at 10 ml/kg/hour until perfusion improves, then 5 ml/kg/hour Use normal saline, half-strength Darrows solution with dextrose, or oral rehydration solution Decrease rate if child has repeated vomiting Transfer to appropriate level of care Slide no 15

16. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 16

17. Rehydration (1) Rehydrate with normal saline Provide maintenance and replace a 10% deficit over 48 hours Do not add urine output to the replacement volume Reassess clinical hydration regularly. Once the blood glucose is <15 mmol/l, add dextrose to the saline (add 100 ml 50% dextrose to every litre of saline, or use 5% dextrose saline) Slide no 17

18. Rehydration (2) If IV/intra-osseous access is not available: • Rehydrate orally with oral rehydration solution (ORS) • Use nasogastric tube at a constant rate over 48 hours • If a NG tube tube is not available, give ORS by oral sips at a rate of 1 ml/kg every 5 min if decreased peripheral circulation, otherwise every 10 min. • Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible Slide no 18

19. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 19

20. Insulin therapy (1) Start insulin after your ABCs (treat shock, start fluids) - stability has improved Insulin infusion of any short acting insulin at 0.1U/kg/hour (0.05 U/kg/hr if younger than 5 years) Rate controlled with the best available technology (infusion pump) Do not correct glucose too rapidly. Aim for decrease of 5 mmol/l per hour Slide no 20

21. Insulin therapy (2) • Example: • A 24 kg child will need 2.4 U/hour • Put 24 U short acting insulin into 100 ml saline and run at 10 ml/hour • Equivalent to 0.1 U/kg/hour • Younger children: lower rate e.g. 0.05 U/kg/hour Slide no 21

22. Insulin therapy (3) • If no suitable control of the rate of the insulin infusion is available OR • No IV access use sub-cutaneous or intra-muscular insulin. • Give 0.1 U/kg of short-acting regular or analogue insulin subcutaneously or IM into the upper arm • Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible Slide no 22

23. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 23

24. Electrolyte deficits The most important is potassium Every child in DKA needs potassium replacement Other electrolytes can only be assessed with a laboratory test Obtain a blood sample for determination of electrolytes at diagnosis of DKA Slide no 24

25. ECG and Potassium Levels

26. Potassium (1) Levels determined by laboratory test If not available, can use ECG (T waves) Start potassium replacement once serum value known or patient passes urine If no lab value or urine output within 4 hours of starting insulin, start potassium replacement Slide no 26

27. Potassium (2) Add KCl to IV fluids at a concentration of 40 mmol/l (20 ml of 15% KCl has 40 mmol/l of potassium) If IV potassium not available, replace by giving the child fruit juice or bananas. If rehydrating with oral rehydration solution (ORS), no added potassium is needed Slide no 27

28. Potassium (3) Monitor serum potassium 6-hourly, or as often as is possible In sites where potassium cannot be measured, consider transfer of the child to a facility with resources to monitor potassium and electrolytes Slide no 28

29. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 29

30. Acidosis Usually due to ketones Poor circulation will make it worse Correction not recommended unless the acidosis is very profound If bicarbonate is considered necessary, cautiously give 1-2 mmol/kg over 60 minutes. Usually not needed Slide no 30

31. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 31

32. Infection Infection can precipitate the development of DKA Often difficult to exclude infection in DKA, as the white cell count is often elevated because of stress If infection is suspected, treat with broad-spectrum antibiotics Slide no 32

33. Principles Correction of shock Correction of dehydration Correction of hyperglycaemia Correction of deficits in electrolytes Correction of acidosis Treatment of infection Treatment of complications Slide no 33

34. Complications • Electrolyte abnormalities • Cerebral oedema • Rare but often fatal • Often unpredictable • Related to severity of acidosis, rate and amount of rehydration, severity of electrolyte disturbance, degree of glucose elevation and rate of decline of blood glucose • Causes raised intra-cranial pressure • Can lead to death Slide no 34

35. Cerebral Oedema (1) • Presents with • Change in neurological state (restlessness, irritability, increased drowsiness or seizures) • Headache • Increased blood pressure and slowing heart rate • Decreasing respiratory effort • Focal neurological signs • Diabetes insipidus: unexpected/increased urination Slide no 35

36. Cerebral Oedema (2) Check blood glucose Reduce the rate of fluid administration by one-third. Give hypertonic saline (3%), 5 ml/kg over 30 minutes - repeat if needed Mannitol 0.5-1 g/kg IV over 20 minutes may be an alternative Elevate the head of the bed Nasal oxygen Intubation may be necessary for a patient with impending respiratory failure Slide no 36

37. Monitoring • Use forms: • Record hourly: heart rate, blood pressure, respiratory rate, level of consciousness, glucose. • Monitor urine ketones • Record fluid intake, insulin therapy and urine output • Repeat urea & electrolytes every 4-6 hours • Once the blood glucose is less than 15 mmol/l, add dextrose to the saline • Transition to subcutaneous insulin Slide no 37

38. DKA – In Summary Life threatening condition Requires care at the best available facility Morbidity and mortality reduced by early treatment Adequate rehydration and treatment of shock crucial Written guidelines should be available at all levels of the healthcare system Slide no 38

39. Questions

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