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DKA Management in a 6-year-old Child

This case study discusses the management of a 6-year-old child with DKA (Diabetic Ketoacidosis) upon admission to the emergency department. It includes information on the patient's condition, diagnostic criteria, goals of therapy, fluid therapy, insulin therapy, and monitoring.

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DKA Management in 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 Farvardin 1395

  3. Case study • کودک 6 ساله ای با وزن 20 کیلو گرم با تنفس تند به اورژانس وارد شده • در بدو ورود • تصمیم 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. Fluid therapy • Maintenance • Deficit • Abnormal ongoing loss

  21. 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.

  22. Fluid therapy 1-within first 12 hours ½Deficit +½ Maintenance 2- within next 12 hours 1̸ 4Deficit + ½ Maintenance • To replace the estimated fluid deficit evenly Over36- 48 h. ISPAD clinical practice consensus guidelines 2014

  23. First Method • WT=20kg • Maintenance =1500cc • Deficit =100 *20 2000cc • مایع 12 ساعت اول 750+1000=1750 • مایع 12ساعت بعدی 750+500=1250 در واقع در 12 ساعت دوم و سوم بیمار هر بارcc1250 مایع دریافت می کند

  24. Second Method • Iv rate= 85cc/kg+maintenance- bolus÷ 23hr • Iv rate= 85* 20 +1500-300 ÷ 23hr • Iv rate= 126 cc /hr Nelson 2014

  25. Third Method • First day 1.5-2 times the 24 h maintenance requirements • 10-20ml · kg-1 · h • with isotonic solution 0.9% saline,Ringer’s lactate for at least 4–6 h • Then half salin 0.45% salin • The second day 1-1.5 times the 24 h maintenance requirements • Pediatric Diabetes 2014 • ISPAD clinical practice consensus guidelines 2014

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

  27. 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

  28. Volume Expansion • 10-20 ml/kg NS within 60-120 minutes

  29. Volume Expansion Repeated 10ml/kg if • Shock • Hypotension • Delay capillary refilling • Decrease tissue perfusion

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

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

  32. مایع 6 ساعت بعدی • 126*6 = 756 cc • دکستروز5% همراه با 75 میلی اکی والان درلیتر سدیم • 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

  33. 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

  34. Fluid therapy Acidosis with BS 100-200mg/dl • Add%7.5 dextrose to solution • Insulin should be continue

  35. Fluid therapy Acidosis with BS <100mg/dl • Add%10 dextrose to solution • Insulin should be continue

  36. Fluid therapy . • 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

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

  38. Fluid therapy • NS with added potassium was used after urination Pediatr Crit Care Med 2004 Vol. 5, No. 5

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

  40. Potassium • K=3-4 40mEq/l • K=4-5 20mEq/l • k<3mEq/l insulin should be hold temporary • Give 0.5 -1mmol/kg/h iv and oral EndocrinolMetabClin N Am 35 (2006) 725–751

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

  42. Bicarbonate Therapy After 2-3hours of hydration if • pH <7.0 or bicarbonate <5 mEq • Give 1meq/kg over 1 hour

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

  44. 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

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

  46. WARNING SIGNS • BG falls >90 mg/dL/hour • Headache • Slowing heart rate • Irritability • Decreased conscious level • incontinence • specific neurological signs • Hypoglycemia

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

  48. Insulin therapy • The administration of insulin without fluid replacement in such patients with hypotension may aggrevate hypotension

  49. درمان با انسولين • روش اول– مداوم ابتدا در cc100 نرمال سالين ، 10 واحد انسولين كريستال مي ريزيم و براي بيمار 0.1iu/kg انسولين شروع مي كنيم تا قند خون به 300 برسد. پس از آن درمان به طريق زیررا بر اساس درجه اسيدوز با يكي از دو روش ذيل ادامه مي دهيم • اگر اسيدوز باقي باشد دوز انسولين را با نصف ادامه مي دهيم • اگر اسيدوز بر طرف شده باشد ، انسولين مداوم قطح مي گردد.

  50. نرمال سالين را در ميكروست مي ریزیم و هر 60 قطره آن ، cc 1 است . حال اگر كودكي 20 كيلو باشد و ديابت داشته باشد ، بايد درهر ساعت 20×0/1=2U انسولين بگيرد يعني 20 قطره در دقيقه

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