DKA - ACEM Fellowship Notes

#paeds see: [RCH - DKA](https://www.rch.org.au/clinicalguide/guideline_index/Diabetic_Ketoacidosis/), [RMH DKA](bear://x-callback-url/open-note?id=22A47CAA-85AA-404A-A271-EF02969A01FA) See also: [[Euglycaemic DKA]], [[Hyperglycaemic Hyperosmolar state|HHS]], [[Paediatric fluids|paeds IV fluids]] > [!key points] > **DKA Definition:** > - serum glucose >11mmol/L > - venous pH <7.3 or HCO3 <15 > - presence of ketonaemia/ketonuria > --- > - cerebral oedema is a key life-threatening complication of DKA > - hypoglycaemia and hypo/hyperkalemia other issues > - children with DKA are [[hypokalemia|deplete in total body potassium]] regardless of the initial serum potassium level > - remember to [[Blood gas#correct Na for glucose|correct sodium for glucose]] > - children with hyperglycaemia +/- ketosis but no acidosis can be managed w/ s/c insulin some triggers: - lack of endogenous insulin eg first presentation DKA - missed dose insulin, pump failure - excess carb load - pregnancy - any major illness / infection - drugs eg cocaine - medications -- antipsychotics, thiazides # Diagnosis - glucose > 11 mmol/L - pH <7.3 or HCO3 <15 mmol/L - presence of ketonaemia/ketonuria # management per protocol ; may use paeds DKA protocol if paediatric - correct dehydration 10mL/kg bolus in kids then ongoing infusion - insulin infusion - 0.05-1 unit/kg/hour - add 40 mmol/L KCl to IVF if K <5 and passing urine - add 5% dextrose to fluids when BSL <15 - seek and treat precipitant -- CXR, UA, blood ctx # cerebral oedema - more common in children than adults - ?due to decline in intravascular osmolality → move H2O into brain cells → cerebral oedema - PECARN fluid trial 2018 suggested more rapid fluid infusion was a/w more rapid improvement in scores - new research maybe hypoperfusion and reperfusion, inflammatory responses, play a role in DKA-related cerebral injury risk factors: severe acidosis, increased urea, lower CO2, age <5 and new-onset diabetes **diagnosis** - abnormal or deteriorating mental status after initiation of therapy, agitation - inappropriate slowing of heart rate, eg ↓ 20 BPM not due to increase in volume - incontinence - minor criteria: - headache - vomiting - irritability, lethargy - increase BP - severe: - decorticate posture - abnormal pupillary response or other CN palsy - neurogenic resp pattern eg grunting **Treatment** - *mannitol* 0.5-1g/kg IV over 10-15 min . can repeat after 30 min - second line 2.5-5ml/kg [[hyponatremia|hypertonic saline]] over 10-15 min - adjust fluid rate and aim normal BP, optimise cerebral perfusion (often reduce rate by 30%) - O2 as needed maintain normal O2 +/- intubation if abnormal resp - avoid hypercaponea - raise head of bed to 20-30 deg --- # RCH DKA guidelines | Stage | Actions | | -------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | ARRIVAL | **PRIMARY SURVEY** <ul><li>Assess severity of dehydration . Please weigh child.</li><li>Assess severity of DKA </li><li>Well looking child? Consider capillary gas and ketones. Mild DKA? Discuss with paediatrics.</li><li>Intravenous (IV) access x two, and initial bloods including VBG, UEC, CMP, FBC.</li></ul> | | RESUS? | **Is RESUSCITATION required?** <ul><li>AIRWAY</li><li>BREATHING: supplemental oxygen, aim SpO2 97 to 100%</li><li>CIRCULATION: Treat SHOCK 10 mL/kg sodium chloride 0.9% BOLUS. Repeat if shock persisting.</li><li>Shock: tachycardia, prolonged central capillary time. Hypotension is a late sign.</li><li>DISABILITY: nurse 30 degrees head up; consider nasogastric tube if altered conscious state.</li></ul> | | IV FLUIDS | Calculate fluid requirements and start IV rehydration. <ul><li>The majority of patients should be assumed to be moderately dehydrated (7%).</li><li>If K ≤ 5.5, add potassium 40 mmol/L to rehydration fluids if child is passing urine.</li></ul> keep NBM until child is alert and acidosis resolved; can have ice for comfort | | 1 HOUR | **After one hour of intravenous (IV) rehydration:** <ul><li>Start insulin infusion: Actrapid 0.1 unit/kg/hour or if less than five years old 0.05 unit/kg/hour.</li><li>Change fluids: add potassium to fluids if potassium less than 5.5 mmol/L and urine output established.</li><li>Use sodium chloride 0.9% + potassium chloride 40 mmol/L 1000 mL premixed bag.</li></ul> | | CRITICAL OBS | <ul><li>Continuous cardiac monitoring if severe DKA, potassium abnormalities, or administration of potassium exceeds 0.2 mmol/kg/hour.</li><li>Recheck potassium within an hour of commencing insulin.</li><li>Hourly: BGL, HR, RR, BP, neurological status, strict fluid balance.</li><li>Every two hours: VBG and blood ketones, recalculate corrected sodium.</li><li>Two to four hourly: UEC, CMP.</li></ul> | | FURTHER REVIEW | <ul><li>If BGL falls below 15 mmol/L: add glucose 5% to intravenous (IV) rehydration fluids.</li><li>If BGL is falling faster than 5 mmol/L/hour or falls below 5 mmol/L: increase glucose concentration in intravenous rehydration fluids.</li><li>If BGL is falling faster than 5 mmol/L/hour and intravenous fluids glucose concentration is at 10%:<ul><li>Reduce insulin infusion rate by 0.01 to 0.02 unit/kg/hour</li><li>Do not stop insulin infusion if patient remains acidotic or ketotic.</li></ul></li><li>Signs of neurological deterioration?<ul><li>Exclude hypoglycaemia: if BGL less than 4 mmol/L, give 2 mL/kg 10% glucose intravenous bolus and increase glucose concentration in rehydration fluids</li><li>Is it cerebral oedema? URGENT SENIOR MEDICAL STAFF REVIEW</li></ul></li><li>Acidosis not improving? SENIOR MEDICAL REVIEW.<ul><li>Insufficient insulin? Check insulin delivery</li><li>Inadequate rehydration? Consider sepsis or other form of shock</li></ul></li></ul> | ## Initial fluid rates see: [[dehydration|paediatric dehydration assessment]] - Mild (<4%): No clinical signs -- ~40 mL/kg fluid deficit - Moderate (4-7%): Decreased tissue turgor, poor central capillary return -- ~ 70 mL/kg fluid deficit - Severe (>7%): Shock, poor perfusion, rapid pulse, hypotension -- ~100mL/kg fluid deficit | Weight (kg) | Mild/nil dehydration <4% (mL/hr) | Moderate Dehydration (4 - 7%) (mL/hr) | Severe Dehydration >7% (mL/hr) | | ----------- | ------------------------------------ | ----------------------------------------- | ---------------------------------- | | **5** | 24 | 27 | 31 | | **7** | 33 | 38 | 43 | | **8** | 38 | 43 | 50 | | **10** | 48 | 54 | 62 | | **12** | 53 | 60 | 70 | | **14** | 60 | 65 | 80 | | **16** | 65 | 75 | 85 | | **18** | 70 | 80 | 95 | | **20** | 75 | 85 | 105 | | **22** | 80 | 90 | 110 | | **24** | 80 | 95 | 115 | | **26** | 85 | 100 | 120 | | **28** | 85 | 105 | 125 | | **30** | 90 | 110 | 135 | | **32** | 90 | 110 | 140 | | **34** | 95 | 115 | 145 | | **36** | 100 | 120 | 150 | | **38** | 100 | 125 | 155 | | **40** | 105 | 130 | 160 | | **42** | 105 | 135 | 170 | | **44** | 110 | 135 | 175 | | **46** | 115 | 140 | 180 | | **48** | 115 | 145 | 185 | | **50** | 120 | 150 | 190 | | **52** | 120 | 155 | 195 | | **54** | 125 | 160 | 205 | | **56** | 125 | 160 | 210 | | **58** | 130 | 165 | 215 | | **60** | 133 | 171 | 220 | | **62** | 136 | 175 | 226 | | **64** | 139 | 179 | 232 | | **66** | 140 | 185 | 240 | | **68** | 145 | 185 | 245 | | **70** | 150 | 190 | 250 | ## fluid adjustments > frequent monitoring of electrolytes, glucose, and osmolality will guide composition and infusion rates. fluids with 0.9% NaCl should be continued for at least first 6 hours [[Osmolality and Osmolarity|osmolality]] = 2xNa + glucose + urea | parameter | issues | | --------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | glucose | - when BGL ≤ 15, Δ fluids to 0.9% saline + 5% dextrose +/- KCl (max 60 mmol/L) - aim BGL 5-10 - if BGL < 5 mmol?L or ↓ > 5 mmol/L/H in rage btn 5-15, *increase glucose content to 10%* - only ↓ insulin infusion rate if BGL continues to decrease in spite of 10% dextrose | | potassium | once insulin commenced, measure K within 1 hour and then Q 2-4 hours thereafter start KCl at 40 mmol/L, ↑ to max of 60 mmol/L to maintain K in normal range | | sodium | correct sodium (Na-5)/3 + Na | | phosphate | rarely required. replace if levels <0.32 | ## Complications ### Cerebral Oedema > - clinical cerebral oedema occurs suddenly, usually *btwn 6-12 hours after starting therapy* > - risks: first presentation, long hx of poor control, age <5 1. **Recognition** - Early warning signs: - Headache, irritability - Unexplained heart rate deceleration - Age-inappropriate incontinence - Lethargy, drowsiness - Late signs: - Decreased conscious state - Focal neurological signs - Abnormal posturing - Pupillary changes - Hypertension, bradycardia, resp impairment (very late) 2. **Immediate Actions** - Call emergency response team - Reduce fluid rate by one-third - *Give Mannitol* 20% (0.2g/mL) dose 0.5 g/kg IV over 20 mins ( Hypertonic saline 3% 3mL/kg over 10-15 mins if no mannitol) - repeat if no improvement within 30-60 min - give the mannitol immediately; don't wait for CT scan - Head of bed 30° - Urgent CT scan once stabilised ### Hypoglycaemia > BGL <4.0 mmol/L needs treatment - 2 mL/kg 10% glucose bolus (repeat if needed) and Δ rehydration fluids to have 10% glucose with 0.9% NaCl - don't discontinue insulin infusion - if hypoglycaemia occurs despite 10% glucose in past 2 hours, ↓ insulin infusion to 0.05 u/kg/h (0.03 u/kg/h if previously on 0.05 ) - cont with 10% glucose in fluids until BGL is stable btwn 5-10 mmol/L - recheck BGL after 15-20 min and give another serve of juice or jelly beans if if BGL still <4.0. can use oral treatment for hypos if pH ≥ 7.3 and child is alert and able to tolerate orals - 4-5 jelly beans or juice 60 mL (5g carbohydrate) for children <25kg, 120 mL (10g carbs) for children ≥ 25kg # Related Questions ## dka - [ ] 18Q: [DKA](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=3) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=4) - [ ] 19Q: [Diabetic Ketoacidosis](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=29) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=12) - [ ] 20Q: [Diabetic Ketoacidosis](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=21) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=7) - [ ] 21Q: [Diabetic Ketoacidosis](x-devonthink-item://707C2E83-C5B4-4D98-99ED-FC32BF6F417F?page=1) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=9) -- [prop](x-devonthink-item://D5D52721-F021-4ABC-B6EA-727BF54DF6B9?page=6)