Management of Diabetic Ketoacidosis in the PICU

Report
Management of
Diabetic Ketoacidosis
in the PICU
PICU Resident Lecture Series
DKA - A common PICU diagnosis
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Incidence 4.6 – 8 per 1000 person years
among people with diabetes
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Pediatric mortality rate is 1-2%
DKA causes profound dehydration
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Hyperglycemia leads to osmotic diuresis
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Often 10-15% down from baseline weight
Profound urinary free water and electrolyte
loss
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Free water follows glucose into urine
Electrolytes follow free water into urine
Electrolyte abnormalities
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Pseudo-hyponatremia with hyperglycemia
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Profound total-body K+ depletion
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Sodium should rise with correction of glucose
Urinary loss, decreased intake, emesis
Initial K+ may be high due to acidosis, low insulin
Aggressive K+ replacement necessary to prevent
arrhythmias
Phosphate, magnesium, calcium require
replacement
Initial DKA management - ED
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Resuscitation aimed at shock reversal
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Begin with 10-20 mL/kg NS bolus, may repeat if
signs of shock persist
Bolus fluids only necessary if signs of shock
present
Avoid overly-aggressive fluid resuscitation
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Concern for inciting cerebral edema, though no
clear data
Initial DKA management - ED
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NEVER give bicarbonate
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Increases risk of cerebral edema
Begin insulin infusion at 0.1 units/kg/hr
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Should be initiated prior to leaving ED
SQ or bolus insulin not indicated
Pre-PICU arrival
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Order several bags of dextrose-containing
and non-dextrose-containing IVF pre-PICU
arrival
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Often takes pharmacy 1 hour to custom-make
IVF
No dextrose-containing fluids stocked in PICU
Fluid Management - PICU
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3 components to replacement fluids
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Deficit (often 10-15% total body water deficit)
Ongoing losses (polyuria, emesis)
Maintenance
Possible to calculate the above, or give:
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1.5X maintenance if moderately dehydrated
2X maintenance if severely dehydrated
Initial IVF
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Isotonic fluid with potassium
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NS + 20 mEq/L KCl + 20 mEq/L KPhos
Start with 40 mEq/L of potassium if K+ < 5
K+ often split between KCl and KPhos to avoid
hyperchloremic metabolic acidosis
NS preferred to help prevent cerebral edema
Adding dextrose
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Add dextrose to IVF when glucose < 300
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2 bag system allows titration of dextrose
based on glucose
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Bag 1: NS + 20 KCl + 20 KPhos
Bag 2: D10 NS + 20 KCl + 20 KPhos
Titrating dextrose
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2 bag system example: Total IVF rate =
160 mL/hr
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Fingerstick glucose = 280
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Bag 1: NS + 20 KCl + 20 KPhos @ 120 mL/hr
Bag 2: D10 NS + 20 KCl + 20 KPhos @ 40 mL/hr
Fluids “Y” together, dextrose concentration = D2.5
Titrating dextrose
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2 bag system example: Total IVF rate =
160 mL/hr
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Fingerstick glucose = 180
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Bag 1: NS + 20 KCl + 20 KPhos @ 40 mL/hr
Bag 2: D10 NS + 20 KCl + 20 KPhos @ 120 mL/hr
Fluids “Y” together, dextrose concentration = D7.5
Frequent lab monitoring is essential in
DKA
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Glucose q1 hour
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Chem 10 , VBG q4 hours
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To correct venous pH to arterial pH, add 0.04
Serial UAs to monitor for resolution of
glucosuria and ketonuria
DKA vs. Hyperglycemic
Hyperosmolar Syndrome (HHS)
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HHS more likely in older, obese patients
with Type II DM
Lab features of HHS
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More severe hyperglycemia than DKA
Less severe or absent acidosis
Trace or absent ketones in urine
Can have normal serum bicarb
Serum osmolality > 320
Importance of Insulin
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Insulin is the only therapy that corrects the
underlying pathophysiology in DKA
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Increase dextrose as necessary to continue
insulin infusion at 0.1 units/kg/hr
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Do NOT titrate insulin drip
Transitioning to SQ insulin
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May consider transition when:
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Bicarb > 18, pH > 7.3, AG <12, GCS 15, emesis
resolved
How to transition – order of events:
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Fingerstick glucose pre-meal  eat meal  give
SQ insulin  stop drip
May re-check VBG post-meal to ensure that
acidosis has not recurred
Complications of DKA
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Cerebral Edema
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Vasogenic vs. cytotoxic, unclear etiology
Risk factors:
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Age <5 years
High BUN (severe dehydration)
Severity of acidosis
Bicarbonate administration
New-diagnosis diabetes
Na levels don’t rise as expected with treatment
Cerebral Edema
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Hourly neuro / pupillary checks
Mannitol 0.5 g/kg at bedside
Consider 3% NaCl bolus 3-5 mL/kg if Na drops
with therapy
Stat head CT for any concerning mental status
changes
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Give mannitol prior to going to CT!
If CT reveals cerebral edema and GCS is <8,
consult neurosurgery for ICP monitoring
Complications of DKA
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Thrombosis
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Dehydration, low flow state
Avoid central lines if possible
ARDS
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Rapid fluid resuscitation with low albumin at
baseline  capillary leak, pulmonary edema
Rare complication in pediatric DKA
Complications of DKA
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Hyperchloremic metabolic acidosis
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Hypoglycemia
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May check urine for ketones if unsure whether DKA has
resolved
Rare with appropriate dextrose titration
Hypokalemia
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Can lead to fatal arrhythmias
K+ must be repleted aggressively
10 Tips for Managing DKA in PICU
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2 large-bore PIVs
Frequent lab
monitoring
Hourly neuro checks
Watch for falling
sodium
Correct hypokalemia
aggressively
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NEVER give bicarb
Do NOT titrate insulin
drip
Mannitol to bedside
Order IVF pre-PICU
arrival
Search for underlying
cause (infection, noncompliance, etc.)

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