Diabetic ketoacidosis (peds)

Background

• (pH <7.25-7.30 or bicarb <15) + hyperglycemia (>300) + ketonemia (>1:2 serum dilution)
• DKA + AMS = cerebral edema until proven otherwise

Cerebral Edema

Risk Factors

1. Age <5yo
   1. Rare in >20yo
2. Severe hyperosmolality
3. Failure of Na to rise w/ therapy
4. Severe acidosis
5. Overaggressive fluid resus is NOT a risk factor

Diagnosis

• Begins 6-12hr after onset of therapy
• Many appear to be improving from their DKA before deteriorating from cerebral edema
• Premonitory symptoms:
  • HA, declining mental status, sz, respiratory arrest

Treatment

• Mannitol 0.5-1gm/kg IV bolus OR 3% saline 10mL/kg over 30min
• Fluid restriction

Treatment

• IV Fluids
  • NS @ 10ml/hr/kg for stable VS
  • Bolus 20ml/kg NS only for unstable VS
  • Replace fluid deficit evenly over 48hr w/ NS or 1/2 NS
  • When BS <250:
    • Change fluid to D51/2NS @ rate to correct fluid deficit in 48hr; maintain BS 150-250
• Insulin
  • IV Infusion 0.1 units/kg/hr
    • Cont until HCO3 > 15 and pH>7.3
  • Decrease infusion to 0.05 u/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
  • Only consider for:
    • Critically ill (hemodynamic compromise from decr contractility) AND
    • pH <7.0
  • 0.5-2 mEq/kg over 1-2hr
  • Correction should never exceed pH > 7.1 or bicarb >10

Disposion

• Admit all except can consider dischage if:
  • Known diabetes
  • pH > 7.35 and bicarb > 20
  • Known and resolving precipitant for DKA

Source

Tintinalli