When Kids Are Sweet as Sugar
and
Sick as *&#!
Teri Campbell RN, BSN, CEN, CFRN
University of Chicago Aeromedical Network
Aerocare
DKA
• Complex metabolic state
• Emergency vs. life-threatening
• Hospitalizations
• Cerebral edema
Objectives
• Participants will define DKA
• Participants will identify precipitating factors
• Participants will discuss common presentation
• Participants will review pre-hospital vs.
hospital stabilization goals
• Participants will discuss treatment options
• Participants will review potential complications
Definition
Triad
• Hyperglycemia
• Ketonemia
• Acidemia
That’s a lot of “emias”…
Definition
• Blood glucose: > 250 mg/dl
• PH: < 7.3
• Serum Bicarbonate: < 15 mEq/L
• Urinary ketone: > = 3+
• Serum Ketone: positive at 1:2 dilutions
• Serum osmolality: Variable
All the stats…
• Incidence / frequency
• Race
• Mortality
Precipitating factors
• New diagnosis
• Infections
• Non-compliance
• Endocrine changes
• Caregiver lack of compliance
• Pump failure
What a story…
History
• Polydipsia, Polyuria
• Fatigue
• Malaise
•N/V
• Weight loss
• Fever
History
Abdominal
pain
Pathology
Decreased Insulin
Increase of “stress hormones”
• catecholamines
• glucagon
• growth hormone
• cortisol
Pathology
Lots and lots of sugar to no avail…
• Proteolysis
• Ketones
• Lipolysis
• Lactic acids
Presentation
Soooo… How do they LOOK?
• mental status changes
• tachycardia
• kussmaul
• B/P
• delayed cap refill
• possibly febrile
Hyperglycemia
• High serum glucose
• Big sponge
Dehydration and thirst
• Intra-cellular dehydration
• Extra-cellular fluid expansion
• Hyponatremia
• Polyuria
• H20 losses exceed NaCl losses
• Decrease urine blood flow
• Glucose retention
Acidosis
2 main culprits
Ketones : Proteolysis
Lactic acid: Lipolysis
Tissue hypoperfusion
Hyperosmolality
• Directly related to hyperglycemia
• Increased serum osmols
• Increased cerebral osmols
Electrolyte disturbances
• NA: low, normal or high
• Increased K+
• Decreased K+
Treat hypokalemia first or…ZAP!
Fluids → K+ → Insulin
Labs
• Glucose
• K+
• ABG’s
• Electrolytes: CL, HCo3, BUN, Cr, Phos
Labs
• CBC
• blood / urine culture
• UA
• serum osmolality
• EKG: hyperK+ = peaked T waves
SHOCK hyperkalemia? _______
Pre-hospital
• A: mental status changes
• B: O2, BVM, Sellicks
• C: Isotonic fluids
• 20 cc/kg X ONE…
• What size IV?
Pre-hospital
• D: Altered mentation?
• History?
Long transport?
It’s time we face reality, my friends
Global goals
• Restore perfusion
• Give insulin
• Correct electrolyte disturbances
• Avoid complications
Where are we going?
And why am I in this
Hand basket?
Fluid therapy
• 1st 1-2 hours of therapy
• Isotonic 20cc/kg
• Shock
• 0.9 NS vs. 0.45 NS
• 1.5 – 2.0 X maintenance
• BSA: 1200cc/M2/day
Fluid therapy
•
•
•
•
4-2-1 Rule
1st 10 kg : 40 cc
2nd 10 kg : 20 cc
1cc for every kg over (20kg)
1st 10 kg: 40cc
2nd 10 kg: 20 cc
all the other kg (1cc/kg): 17 cc
77 cc/hr
37 kg child:
Potassium supplement
• Profound hypoK+: oral vs. IV
• Treat before insulin
• K+ > 5.5: No K+ to IVFs
• KCL vs K phosphate
Slowwwww lab?
Insulin
• Bolus controversy
• timing controversy
• prime the tubing
• 0.1 units/kg/hr
• 0.05 units/kg/hr
• clear ketones
• Regular insulin 1:1
Bicarbonate
• Rarely indicated
• Evidence?
• PH < 7.0
• Adverse hemodynamic effects
• Hypokalemia, hyperNA, alkalemia
• Never give IV push
Glucose
• Blood sugar @ 250 mg/dL
• D5, D10
• Ketones, prevent hypoglycemia
• serum glucose: 100-150 mg/dL
150-250 mg/dL
• Fall: 50-70 mg/dL / first hour
Serum Osmolality
• Normal range
• > 320 risk for cerebral edema
• > 320 correct volume over 36 hours
• > 340 correct volume over 48 hours
Complications
Cerebral edema
• More common kids / adol.
• Incidence: 0.3-1.0%
• Mortality: 70%
• Risk factors
• Presentation
Pathology
• Hyperglycemia = high serum osmols
• High serum osmols = high brain osmols
• Rapid correction: volume or sugar
• Gradient: intracerebral & serum osmols
• Free H20 into brain
Treatment
Initial CT
Mannitol
Hypertonic
saline
ARDS
• Rare
• Potentially fatal
• Lots of crystalloids
• Normal cardiac function
Key points
• Often misdiagnosed
• Replace cellular and intravascular losses
• Insulin to allow glucose utilization
• Possible correction of electrolytes
• Prevent complication
In conclusion…
Keep it slow…..
It took them weeks to get here…
It will take days to fix them….
When Kids Are Sweet as Sugar
and
Sick as *&#!
Teri Campbell RN, BSN, CEN, CFRN
University of Chicago Aeromedical Network
Aerocare
tlcsoup@aol.com