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DKA in Kids

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April 27, 2021

Diabetic Ketoacidosis – remember in paediatrics this may be the 1st presentation of diabetes.

  • Fluid – are more considered that adults due to the risk of cerebral oedema
  • Insulin – WAIT – need 1hr of fluid first
  • Paeds – involve them early

DKA Management Calculator (recommended by paediatrics)- HERE

(Blank Pathway – HERE)

Confirm DKA

Clinical

  • Acidotic Respiration
  • Dehydration
  • Drowsy [Monitor mental state hourly]
  • Abdominal Pain/Vomit

Biochemical – should have ALL of following

  • Blood Glucose >11mmol/l
    • children and young people with known diabetes may develop DKA with normal blood glucose levels.
  • Blood pH <7.3 &/OR HCO3 <15mmol/l
  • Blood Ketone >3mmol/l

Severity

  • MILD –  pH 7.2- 7.29 &/or HCO3< 15
  • MODERATE – pH  7.1-7.19 &/or HCO3 < 10
  • SEVERE – pH <7.1 &/or HCO3 < 5

Investigations

  • Blood Glucose
  • U&E
  • FBC
  • Venous/Capillary Gas
  • Blood Ketone
    • 0 – 0.5 [Negative – Low]
    • 0.6 – 1.5 [Low – Moderate]
    • 1.6 – 3 [Moderate]
    • >3 [High]
  • Chloride, Calcium, Phosphate
  • Consider Blood cultures (fever is not part of DKA)
  • NEW DIAGNOSIS (and able to get enough blood) – HBA1C, TFT, Coeliac screen

Initial fluid Bolus

  • NOT Shocked (but judged to require fluids)- 10ml/kg 0.9% NaCl over 60 min
  • Shocked – 20ml/kg 0.9%NaCl over 15 min
    • May give further 10ml/kg boluses if required up to total 40ml/kg (then inotrops indicated)

Fluid deficit & Maintenance

DKA Management Calculator (recommended by paediatrics)

  • MILD (5% deficit)–  pH 7.2- 7.29 &/or HCO3< 15
  • MODERATE (7% deficit) – pH  7.1-7.19 &/or HCO3 < 10
  • SEVERE (10% deficit) – pH <7.1 &/or HCO3 < 5

Deficit Calculation (ml) = % dehydration x Weight[kg] x 10

    • 5% deficit = 50ml/kg/48hr
    • 7% deficit = 70ml/kg/48hr
    • 10% deficit = 100ml/kg/48hr
  • Replace over 48 hours – use 0.9% NaCl with 20 mmol KCl in 500 ml
  • Initial fluid bolus- what to do?
    • Non-Shocked (but requiring fluid) – 10ml/kg [Subtract from total]
    • Shocked – resuscitation fluid [DO NOT Subtract from total]

Maintenance

  • First 10kg body weight- 100 ml/kg/day
  • Second 10kg body weight – 50 ml/kg/day
  • Additional kilogram above 20 kg – 20 ml/kg/day

 

Blood Glucose under 14mmol/l

  • Use: 0.9% NaCl + 20mmol KCl + 5% dextose

Sodium Correction – D/W Paeds senior

Insulin

  • ONLY Start 1-2hr after fluid therapy begins
  • There is no need to start in ED [unless prolonged stay]
  • Evidence: Early insulin increases likelihood of Cerebral Oedema

USE: 50 unit Actrapid in 49.5ml 0.9% NaCl [Syringe pump must be used]

Dose

  • Insulin infusion – 0.05unit/kg/hour (0.05ml/kg/hour)
  • Blood Glucose <14mmol/l  – change fluid 0.9% NaCl + 20mmol KCl + 5% dextrose
  • Blood Glucose <4mmol/l  – Bolus 2ml/kg 10% dextrose
  • Blood Glucose not falling – Consider increase to 0.1unit/kg/hr [D/W Paeds]

BSPED Fluid Calculator:BSPED fluid calculator

Full GUIDE:dkap