Diabetic ketoacidosis (peds)

Background

• DKA + altered mental status = cerebral edema until proven otherwise

Clinical Features

History

• May be the initial presenting of an unrecognized Type-1 diabetes mellitus patient
• Presenting signs/symptoms include altered mental status, tachypnea, abdominal pain
• Perform a thorough neurologic exam (cerebral edema increases mortality significantly, especially in children)
• Assess for possible inciting cause (esp for ongoing infection; see Differential Diagnosis section)
• Keep in mind that the initial presentation of sepsis with dehydration can look very similar to DKA

Physical

• Drowsiness
• Tachypnea (Kussmaul's breathing)
• Signs of dehydration
• Perform a thorough neurologic exam as cerebral edema increases mortality significantly, especially in children
• There may be signs from underlying cause (eg pneumonia)

Differential Diagnosis

Hyperglycemia

• Diabetic foot infection
• Diabetic ketoacidosis (DKA)
• Diabetic ketoacidosis (peds)
  • Cerebral edema in DKA
• Hemochromatosis
• Hyperosmolar hyperglycemic state (HONC)
• Iron toxicity
• New onset diabetes mellitus
  • Diabetic peripheral neuropathy
• Nonketotic hyperglycemia
• Sepsis

Evaluation

Workup

• Point of care glucose (and potassium, if available)
• CBC
• Chem 7
• Magnesium
• Phosphorus
• Serum ketones (or beta-OH and acetone)
• Urinalysis
• Urine pregnancy (if appropriate)
• VBG
• Consider studies for possible infectious trigger

Diagnosis

• Hyperglycemia (>200)
• Acidosis
  • pH <=7.30 or bicarb <=15
• +ketonemia (>1:2 serum dilution)

General Treatment

• Initial bolus 20ml/kg NS x 1 (repeat boluses only for shock or poor perfusion)

Manage Hydration

• If K+<5.5
  • 0.45% NS (or NS) + 20 KPhosat 1.5 x maintenance rate
    • When BS <300, change to D5/0.45%NS (or NS) +20 KPhos at 1.5 x maintenance rate (maintain BS 150-250)

Manage Acidosis

• Insulin drip 0.1 units/kg/hr
  • Do not start if K+ <4.0 (repleate K+ first)
  • Cont until HCO3 >15 and pH >7.3, then initiate SC insulin
    • Decrease infusion to 0.05 units/kg/hr until 1hr after SC insulin initiated

Potassium

• if < 2.5, hold insulin and give 1 meq/kg KCL in IV over 1hr
  • No insulin until K > 2.5
• if > 2.5 but < 3.5 give 40-60 meq/L in IV until K > 3.5
• if > 3.5 but < 5.5 give 30-40 meq/L in IV for K=3.5 - 5
• if > 5.5, then check K q1hr

Bicarbonate

• No evidence supports the use of sodium bicarb in DKA, with a pH >6.9
• However, no studies have been performed for patients with pH <6.9 and the most recent ADA guidelines recommend it for patients with pH <7.1
• Only consider for:
  • Critically ill (hemodynamic compromise from decreased contractility) AND
  • pH <7.0
• 0.5-2 mEq/kg over 1-2hr
  • Correction should never exceed pH > 7.1 or bicarb >10

Monitor for Complications

• Cerebral edema (1% of DKA)
  • Acute change in mental status
  • Signs of herniation
• If present see Cerebral Edema in DKA

Disposition

• Admit all (usually to an ICU if on the insulin drip) unless
  • Known diabetes
  • pH >7.35 and bicarb >20
  • Known and resolving precipitant for DKA

Complications

• Cerebral Edema in DKA

See Also

• Diabetes mellitus (main)
• Diabetic ketoacidosis (main)
• Evidence Review Sodium Bicarbonate in DKA]]

External Links

• Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare

References

Authors

Ross Donaldson