PICU Resident Lecture Series

 Incidence 4.6 – 8 per 1000 person years among people with diabetes
 Pediatric mortality rate is 1-2%

 Hyperglycemia leads to osmotic diuresis
 Often 10-15% down from baseline weight
 Profound urinary free water and electrolyte loss
 Free water follows glucose into urine
 Electrolytes follow free water into urine

 Pseudo-hyponatremia with hyperglycemia
 Sodium should rise with correction of glucose
 Profound total-body K+ depletion
 Urinary loss, decreased intake, emesis
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Initial K+ may be high due to acidosis, low insulin
Aggressive K+ replacement necessary to prevent arrhythmias
 Phosphate, magnesium, calcium require replacement

 Resuscitation aimed at shock reversal
 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
 Concern for inciting cerebral edema, though no clear data

 NEVER give bicarbonate
 Increases risk of cerebral edema
 Begin insulin infusion at 0.1 units/kg/hr
 Should be initiated prior to leaving ED
 SQ or bolus insulin not indicated

 Order several bags of dextrose-containing and non-dextrose-containing IVF pre-PICU arrival
 Often takes pharmacy 1 hour to custom-make
IVF
 No dextrose-containing fluids stocked in PICU

 3 components to replacement fluids
 Deficit (often 10-15% total body water deficit)
 Ongoing losses (polyuria, emesis)
 Maintenance
 Possible to calculate the above, or give:
 1.5X maintenance if moderately dehydrated
 2X maintenance if severely dehydrated

 Isotonic fluid with potassium
 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

 Add dextrose to IVF when glucose < 300
 2 bag system allows titration of dextrose based on glucose
 Bag 1: NS + 20 KCl + 20 KPhos
 Bag 2: D10 NS + 20 KCl + 20 KPhos

 2 bag system example: Total IVF rate =
160 mL/hr
 Fingerstick glucose = 280
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Bag 1: NS + 20 KCl + 20 KPhos @ 120 mL/hr
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Bag 2: D10 NS + 20 KCl + 20 KPhos @ 40 mL/hr
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Fluids “Y” together, dextrose concentration = D2.5

 2 bag system example: Total IVF rate =
160 mL/hr
 Fingerstick glucose = 180

Bag 1: NS + 20 KCl + 20 KPhos @ 40 mL/hr
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Bag 2: D10 NS + 20 KCl + 20 KPhos @ 120 mL/hr
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Fluids “Y” together, dextrose concentration = D7.5

Frequent lab monitoring is essential in
DKA
 Glucose q1 hour
 Chem 10 , VBG q4 hours
 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)
 HHS more likely in older, obese patients with Type II DM
 Lab features of HHS
 More severe hyperglycemia than DKA
 Less severe or absent acidosis
 Trace or absent ketones in urine
 Can have normal serum bicarb
 Serum osmolality > 320

 Insulin is the only therapy that corrects the underlying pathophysiology in DKA
 Increase dextrose as necessary to continue insulin infusion at 0.1 units/kg/hr
 Do NOT titrate insulin drip

 May consider transition when:
 Bicarb > 18, pH > 7.3, AG <12, GCS 15, emesis resolved
 How to transition – order of events:
 Fingerstick glucose pre-meal  eat meal  give
SQ insulin  stop drip
 May re-check VBG post-meal to ensure that acidosis has not recurred

 Cerebral Edema
 Vasogenic vs. cytotoxic, unclear etiology
 Risk factors:
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Age <5 years
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High BUN (severe dehydration)
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Severity of acidosis
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Bicarbonate administration
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New-diagnosis diabetes
Na levels don’t rise as expected with treatment

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Hourly neuro / pupillary checks
Mannitol 0.5 g/kg at bedside
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Consider 3% NaCl bolus 3-5 mL/kg if Na drops with therapy
Stat head CT for any concerning mental status changes
 Give mannitol prior to going to CT!
If CT reveals cerebral edema and GCS is <8, consult neurosurgery for ICP monitoring

 Thrombosis
 Dehydration, low flow state
 Avoid central lines if possible
 ARDS
 Rapid fluid resuscitation with low albumin at baseline  capillary leak, pulmonary edema
 Rare complication in pediatric DKA

 Hyperchloremic metabolic acidosis
 May check urine for ketones if unsure whether DKA has resolved
 Hypoglycemia
 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
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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.)