Presentation title

Emergency Care
Part 1: Managing Diabetic Ketoacidosis (DKA)

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Programme
1 2 3
Managing DKA Treating and preventing hypoglycaemia 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

Nausea Vomiting Abdominal pain Altered level of consciousness

Muscle

Fat

Shock Dehydration
Weight loss Ketones

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Clinical features
Pathophysiology
(Whats wrong) Elevated blood glucose Dehydration

Clinical features
(What do you see) High lab blood glucose, glucose meter reading or urine glucose, polyuria, polydypsia Sunken eyes, dry mouth, decreased skin turgor, decreased perfusion (shock rare) Irritability, change in level of consciousness

Altered electrolytes

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 of of of of of of shock dehydration hyperglycaemia deficits in electrolytes acidosis infection 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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