Presentation title
Emergency Care
Part 1: Managing Diabetic Ketoacidosis
(DKA)
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Programme
1
Managing DKA
2
Treating and preventing hypoglycaemia
3
Surgery in children with diabetes
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Diabetic Ketoacidosis
•
•
•
•
Occurs when there is insufficient insulin action
Commonly seen at diagnosis
Is a life-threatening event
Child should be transferred as soon as possible to the
best available site of care with diabetes experience
Initiate care at diagnosis
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Type 1 Diabetes
• Increased urine
• Dehydration
• Thirst
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DKA
Liver
• Weight loss
• Ketones
Muscle
•
•
•
•
Fat
Nausea
Vomiting
Abdominal pain
Altered level of
consciousness
• Shock
• Dehydration
Weight loss
Ketones
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Clinical features
Pathophysiology
(What’s wrong)
Clinical features
(What do you see)
• Elevated blood
glucose
• High lab blood glucose, glucose meter
reading or urine glucose, polyuria,
polydypsia
• Dehydration
• Sunken eyes, dry mouth, decreased
skin turgor, decreased
perfusion (shock rare)
• Altered electrolytes
• Irritability, change in level of
consciousness
• Metabolic acidosis
(ketosis)
• Acidotic breathing, nausea, vomiting,
abdominal pain, altered level of
consciousness
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Managing DKA
• Refer to best available site of care whenever possible
• Need:
• Appropriate nursing expertise (preferably a high level of
care)
• Laboratory support
• Clinical expertise in management of DKA
• Written guidelines should be available
• Document and use the form
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DKA monitoring form
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DKA monitoring
• DKA protocol available to the clinic
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Principles of DKA management (1)
1.
2.
3.
4.
5.
6.
7.
Correction
Correction
Correction
Correction
Correction
Treatment
Treatment
of shock
of dehydration
of hyperglycaemia
of deficits in electrolytes
of acidosis
of infection
of complications
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Principles of DKA Management (2)
1. Correction of shock or decreased peripheral
circulation – quick phase
2. Correction of dehydration - slow phase
Do not start insulin until the child has been
adequately resuscitated, i.e. good perfusion and
good circulation
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Assessment
• History and examination including:
• Severity of dehydration. If uncertain about this, assume
10% dehydration in significant DKA
• Level of consciousness
• Determine weight
• Determine glucose and ketones
• Laboratory tests: blood glucose, urea and electrolytes,
haemoglobin, white cell count, HbA1c
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Resuscitation (1)
• Ensure appropriate life support (Airway, Breathing,
Circulation, etc.)
• Give oxygen to children with impaired circulation and/or
shock
• Set up a large IV cannula/intra-osseous access.
• Give fluid (saline or Ringers Lactate) at 10ml/kg over
30 minutes if in shock, otherwise over 60 min. Repeat
boluses of 10 ml/kg until perfusion improves
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Resuscitation (2)
• If no IV available, insert nasogastric tube or set up
intraosseous or clysis infusion
• Give fluid at 10 ml/kg/hour until perfusion improves, then
5 ml/kg/hour
• Use normal saline, half-strength Darrows solution with
dextrose, or oral rehydration solution
• Decrease rate if child has repeated vomiting
• Transfer to appropriate level of care
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Rehydration (1)
• Rehydrate with normal saline
• Provide maintenance and replace a 10% deficit over 48
hours
• Do not add urine output to the replacement volume
• Reassess clinical hydration regularly.
• Once the blood glucose is <15 mmol/l, add dextrose to
the saline (add 100 ml 50% dextrose to every litre of
saline, or use 5% dextrose saline)
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Rehydration (2)
If IV/intra-osseous access is not available:
• Rehydrate orally with oral rehydration solution (ORS)
• Use nasogastric tube at a constant rate over 48 hours
• If a NG tube tube is not available, give ORS by oral sips
at a rate of 1 ml/kg every 5 min if decreased peripheral
circulation, otherwise every 10 min.
• Arrange transfer of the child to a facility with
resources to establish intravenous access as soon
as possible
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Insulin therapy (1)
• Start insulin after your ABCs (treat shock, start fluids) stability has improved
• Insulin infusion of any short acting insulin at
0.1U/kg/hour (0.05 U/kg/hr if younger than 5 years)
• Rate controlled with the best available technology
(infusion pump)
• Do not correct glucose too rapidly. Aim for decrease of
5 mmol/l per hour
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Insulin therapy (2)
• Example:
• A 24 kg child will need 2.4 U/hour
• Put 24 U short acting insulin into 100 ml saline and run at
10 ml/hour
• Equivalent to 0.1 U/kg/hour
• Younger children: lower rate e.g. 0.05 U/kg/hour
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Insulin therapy (3)
• If no suitable control of the rate of the insulin infusion
is available
OR
• No IV access use sub-cutaneous or intra-muscular
insulin.
• Give 0.1 U/kg of short-acting regular or analogue
insulin subcutaneously or IM into the upper arm
• Arrange transfer of the child to a facility with
resources to establish intravenous access as soon
as possible
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Electrolyte deficits
• The most important is potassium
• Every child in DKA needs potassium replacement
• Other electrolytes can only be assessed with a
laboratory test
• Obtain a blood sample for determination of electrolytes
at diagnosis of DKA
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ECG and Potassium Levels
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Potassium (1)
• Levels determined by laboratory test
• If not available, can use ECG (T waves)
• Start potassium replacement once serum value known
or patient passes urine
• If no lab value or urine output within 4 hours of starting
insulin, start potassium replacement
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Potassium (2)
• Add KCl to IV fluids at a concentration of 40 mmol/l (20
ml of 15% KCl has 40 mmol/l of potassium)
• If IV potassium not available, replace by giving the
child fruit juice or bananas.
• If rehydrating with oral rehydration solution (ORS), no
added potassium is needed
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Potassium (3)
• Monitor serum potassium 6-hourly, or as often as is
possible
• In sites where potassium cannot be measured,
consider transfer of the child to a facility with
resources to monitor potassium and electrolytes
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Acidosis
• Usually due to ketones
• Poor circulation will make it worse
• Correction not recommended unless the acidosis is very
profound
• If bicarbonate is considered necessary, cautiously give
1-2 mmol/kg over 60 minutes. Usually not needed
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Infection
• Infection can precipitate the development of DKA
• Often difficult to exclude infection in DKA, as the white
cell count is often elevated because of stress
• If infection is suspected, treat with broad-spectrum
antibiotics
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Principles
1.
2.
3.
4.
5.
6.
7.
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
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Complications
• Electrolyte abnormalities
• Cerebral oedema
• Rare but often fatal
• Often unpredictable
• Related to severity of acidosis, rate and amount of
rehydration, severity of electrolyte disturbance, degree of
glucose elevation and rate of decline of blood glucose
• Causes raised intra-cranial pressure
• Can lead to death
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Cerebral Oedema (1)
•Presents with
• Change in neurological state (restlessness, irritability,
increased drowsiness or seizures)
• Headache
• Increased blood pressure and slowing heart rate
• Decreasing respiratory effort
• Focal neurological signs
• Diabetes insipidus: unexpected/increased urination
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Cerebral Oedema (2)
• Check blood glucose
• Reduce the rate of fluid administration by one-third.
• Give hypertonic saline (3%), 5 ml/kg over 30
minutes - repeat if needed
• Mannitol 0.5-1 g/kg IV over 20 minutes may be an
alternative
• Elevate the head of the bed
• Nasal oxygen
• Intubation may be necessary for a patient with
impending respiratory failure
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Monitoring
• Use forms:
• Record hourly: heart rate, blood pressure, respiratory
rate, level of consciousness, glucose.
• Monitor urine ketones
• Record fluid intake, insulin therapy and urine output
• Repeat urea & electrolytes every 4-6 hours
• Once the blood glucose is less than 15 mmol/l, add
dextrose to the saline
• Transition to subcutaneous insulin
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DKA – In Summary
• Life threatening condition
• Requires care at the best available facility
• Morbidity and mortality reduced by early treatment
• Adequate rehydration and treatment of shock crucial
• Written guidelines should be available at all levels of
the healthcare system
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Questions
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