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When Kids Are Sweet as Sugar and Sick as *&#!

When Kids Are Sweet as Sugar and Sick as *&#!. Teri Campbell RN, BSN, CEN, CFRN University of Chicago Aeromedical Network Aerocare. DKA. Complex metabolic state Emergency vs. life-threatening Hospitalizations Cerebral edema. Objectives. Participants will define DKA

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When Kids Are Sweet as Sugar and Sick as *&#!

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  1. When Kids Are Sweet as Sugar andSick as *&#! Teri Campbell RN, BSN, CEN, CFRN University of Chicago Aeromedical Network Aerocare

  2. DKA • Complex metabolic state • Emergency vs. life-threatening • Hospitalizations • Cerebral edema

  3. Objectives • Participants will define DKA • Participants will identify precipitating factors • Participants will discuss common presentation • Participants will review pre-hospital vs. • hospital stabilization goals • Participants will discuss treatment options • Participants will review potential complications

  4. Definition Triad • Hyperglycemia • Ketonemia • Acidemia That’s a lot of “emias”…

  5. Definition • • Blood glucose: > 250 mg/dl • PH: < 7.3 • Serum Bicarbonate: < 15 mEq/L • Urinary ketone: > = 3+ • Serum Ketone: positive at 1:2 dilutions • Serum osmolality: Variable

  6. All the stats… • Incidence / frequency • Race • Mortality

  7. Precipitating factors • New diagnosis • Infections • Non-compliance • Endocrine changes • Caregiver lack of compliance • Pump failure

  8. What a story… History • Polydipsia, Polyuria • • Fatigue • Malaise • N / V • Weight loss • Fever

  9. History Abdominal pain

  10. Pathology Decreased Insulin • Increase of “stress hormones” • catecholamines • glucagon • growth hormone • cortisol

  11. Pathology Lots and lots of sugar to no avail… • Proteolysis • Ketones • Lipolysis • Lactic acids

  12. Presentation Soooo… How do they LOOK? • mental status changes • tachycardia • kussmaul • B/P • delayed cap refill • possibly febrile

  13. Hyperglycemia • High serum glucose • Big sponge

  14. Dehydration and thirst • Intra-cellular dehydration • Extra-cellular fluid expansion • Hyponatremia • Polyuria • H20 losses exceed NaCl losses • Decrease urine blood flow • Glucose retention

  15. Acidosis 2 main culprits Ketones : Proteolysis Lactic acid: Lipolysis Tissue hypoperfusion

  16. Hyperosmolality • Directly related to hyperglycemia • Increased serum osmols • Increased cerebral osmols

  17. Electrolyte disturbances • NA: low, normal or high • Increased K+ • Decreased K+ Treat hypokalemia first or…ZAP! Fluids → K+ → Insulin

  18. Labs • Glucose • K+ • ABG’s • Electrolytes: CL, HCo3, BUN, Cr, Phos

  19. Labs • CBC • blood / urine culture • UA • serum osmolality • EKG: hyperK+ = peaked T waves SHOCK hyperkalemia? _______

  20. Pre-hospital • A: mental status changes • B: O2, BVM, Sellicks • C: Isotonic fluids • 20 cc/kg X ONE… • What size IV?

  21. Pre-hospital • D: Altered mentation? • History? Long transport?

  22. It’s time we face reality, my friends

  23. Global goals • Restore perfusion • Give insulin • Correct electrolyte disturbances • Avoid complications

  24. Where are we going? And why am I in this Hand basket?

  25. Fluid therapy • 1st 1-2 hours of therapy • Isotonic 20cc/kg • Shock • 0.9 NS vs. 0.45 NS • 1.5 – 2.0 X maintenance • BSA: 1200cc/M2/day

  26. Fluid therapy • 4-2-1 Rule • 1st 10 kg : 40 cc • 2nd 10 kg : 20 cc • 1cc for every kg over (20kg) 37 kg child: 1st 10 kg: 40cc 2nd 10 kg: 20 cc all the other kg (1cc/kg): 17 cc 77 cc/hr

  27. Potassium supplement • Profound hypoK+: oral vs. IV • Treat before insulin • K+ > 5.5: No K+ to IVFs • KCL vs K phosphate Slowwwww lab?

  28. Insulin • Bolus controversy • timing controversy • prime the tubing • 0.1 units/kg/hr • 0.05 units/kg/hr • clear ketones • Regular insulin 1:1

  29. Bicarbonate • Rarely indicated • Evidence? • PH < 7.0 • Adverse hemodynamic effects • Hypokalemia, hyperNA, alkalemia • Never give IV push

  30. Glucose • Blood sugar @ 250 mg/dL • D5, D10 • Ketones, prevent hypoglycemia • serum glucose: 100-150 mg/dL • 150-250 mg/dL • Fall: 50-70 mg/dL / first hour

  31. Serum Osmolality • Normal range • > 320 risk for cerebral edema • > 320 correct volume over 36 hours • > 340 correct volume over 48 hours

  32. Complications Cerebral edema • More common kids / adol. • Incidence: 0.3-1.0% • Mortality: 70% • Risk factors • Presentation

  33. Pathology • Hyperglycemia = high serum osmols • High serum osmols = high brain osmols • Rapid correction: volume or sugar • Gradient: intracerebral & serum osmols • Free H20 into brain

  34. Treatment Initial CT Mannitol Hypertonic saline

  35. ARDS • Rare • Potentially fatal • Lots of crystalloids • Normal cardiac function

  36. Key points • Often misdiagnosed • Replace cellular and intravascular losses • Insulin to allow glucose utilization • Possible correction of electrolytes • Prevent complication

  37. In conclusion… Keep it slow….. It took them weeks to get here… It will take days to fix them….

  38. When Kids Are Sweet as Sugar andSick as *&#! Teri Campbell RN, BSN, CEN, CFRN University of Chicago Aeromedical Network Aerocare tlcsoup@aol.com

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