Presentation title Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

Presentation title

Emergency Care

Part 1: Managing Diabetic Ketoacidosis (DKA)

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Managing DKA

Surgery in children with diabetes

Treating and preventing hypoglycaemia

Programme

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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

• Weight loss• Ketones

• Nausea• Vomiting• Abdominal pain• Altered level of

consciousness

• Shock• Dehydration

Liver

Muscle

Fat

Weight lossKetones

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Clinical features

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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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. Treatment 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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. Correction of shock2. Correction of dehydration3. Correction of hyperglycaemia4. Correction of deficits in electrolytes5. Correction of acidosis6. Treatment of infection7. 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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