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Diabetic Ketoacidosis Management in Children
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Diabetic Ketoacidosis Management in Children
, Pediatric DKA Treatment
See Also
Diabetic Ketoacidosis
Diabetic Ketoacidosis Management in Adults
Diabetic Ketoacidosis Related Cerebral Edema
Diabetes Mellitus
Type I Diabetes Mellitus
Type II Diabetes Mellitus
Insulin Resistance Syndrome
Glucose Metabolism
Diabetes Mellitus Education
Diabetes Mellitus Complications
Diabetic Ketoacidosis
Hyperosmolar Hyperglycemic State
Diabetes Mellitus Control in Hospital
Diabetes Mellitus Glucose Management
Hypertension in Diabetes Mellitus
Hyperlipidemia in Diabetes Mellitus
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic Neuropathy
Management
Phase 1 - Fluids in Children (Emergent)
Stabilize shock and
Coma
states first!
Correct Volume Deficit
Initial
Give 10-20 cc/kg NS bolus over first 45 minutes
Both 10 and 20 cc/kg bolus are safe with similar outcomes
Pruitt (2019) Am J Emerg Med 37(12): 2239-41 [PubMed]
Repeat fluid bolus until shock corrected
Next
Fluid deficit replacement distributed evenly over 48 hour period
Start with NS and transition to 1/2 NS over th subsequent 8-10 hours
Rate: 5 ml/kg/hour (1.5 times maintenance)
Use fluids without dextrose (1/2NS) until
Serum Glucose
<250 mg/dl, then use D5 1/2NS
Could also continue NS until
Serum Glucose
<200-250 mg/dl, then transition to D5 1/2 NS
Precautions
Do not drop
Serum Osmolality
(calc) >3 mOsms/hour
Diabetic Ketoacidosis Related Cerebral Edema
Risk of cerebral edema
Slow replacement if
Fluid Overload
risk (and consider close hemodynamic monitoring)
Congestive Heart Failure
Chronic Renal Insufficiency
Follow Intake and output closely
Management
Phase 2 - Acidosis,
Electrolyte
s in children
Potassium Replacement
Precautions
Hypokalemia
must be corrected prior to
Insulin
Hold
Insulin
until
Potassium
>2.5 meq/L in children
Prerequisites
Electrocardiogram
without signs of
Hyperkalemia
Adequate
Urine Output
Administration: Children
Serum Potassium
<2.5 meq/L
Do not administer
Insulin
until
Potassium
>2.5 meq/L
KCl 1 meq/kg (to 40 meq) IV over 1 hour, recheck
This is maximum IV
Potassium
rate!
Requires cardiac monitoring
Requires hourly recheck of
Serum Potassium
Serum Potassium
2.5 to 3.5 meq/L
Give 40-60 meq/L in IV solution
Recheck
Serum Potassium
hourly
Continue replacement until
Potassium
>3.5 meq/L
Serum Potassium
3.5 to 5.0 meq/L
Add 30-40 meq
Potassium
per liter to IV fluids
Serum Potassium
>5.0 meq/L
Do not administer any IV
Potassium
Monitor every 1 hour until <5.0 meq/L
Phosphate Replacement
Indications
Serum Phosphorus
< 0.5-1.0 mg/dl (Severe Depletion)
Controversial - May not be required
Consider if cardiopulmonary adverse affects
Contraindications
Renal Insufficiency
Administration
Determine
Potassium Replacement
as above
Replace part of
Potassium
with
Potassium
phosphate
Potassium
Phosphate: Replace one third
Potassium
Potassium
Chloride: Replace two thirds
Potassium
Magnesium Replacement
Indications
Symptomatic
Hypomagnesemia
(
Magnesium
<1 meq/L)
Administration
MgSO4 50%: 0.2 ml/kg/day IM divide in 3 doses
Sodium Bicarbonate
Replacement
Indications
ABG pH < 7.0 after initial hour of hydration
Other contributing factors
Shock
or
Coma
Severe
Hyperkalemia
Administration
See
Sodium Bicarbonate in Severe Metabolic Acidosis
Add 2 mEq/kg NaCl to NS for a final solution with no more than 155 mEq/L
Sodium
Administer solution over 1 hour
Management
Phase 3 -
Glucose
control in children
Initial
Insulin Dosing
Intravenous protocol
IV
Regular Insulin
drip starting at 0.1 unit/kg/hour
Subcutaneous protocol (if IV not available)
Bolus:
Regular Insulin
0.3 units/kg SC
Maintenance
Per 1 Hour: 0.1 units/kg or
Per 2 Hours: 0.15 to 0.20 units/kg
Maintenance
Continue
Insulin Infusion
until acidosis resolves
When pH>7.3 and serum bicarbonate >15 mEq/L
Decrease
Insulin Infusion
to 0.05 units/kg/hour
Continue
Insulin Infusion
until SC
Insulin
started
Glucose
and electolyte monitoring
Check bedside
Glucose
every 30 min to 2 hours until stable
Add dextrose to replacement fluids when
Serum Glucose
<250 mg/dl (see Fluids above)
Recheck basic metabolic panel every 2-4 hours until stable (see labs below)
Initiate subcutaneous
Insulin Dosing
Known diabetic
Restart prior program and readjust
Insulin
New patient: Determine
Insulin
requirements
Regular 0.1 to 0.25 units per kg
Regular Insulin
every 6-8 hours or
Divide 0.5 to 1 unit/kg/day into twice daily regimen of short and long acting
Insulin
AM (66%): Give 1/3 short acting and 2/3 intermediate to long actng
Insulin
PM (33%): Give 1/2 short acting and 1/2 intermediate to long actng
Insulin
Monitoring
Labs every 2-4 hours until stable
Serum
Electrolyte
s
Serum Creatinine
Blood Urea Nitrogen
Serum Glucose
(checked every 30 min to hour as above)
References
Brink (1999) Diabetes Nutr Metab 12:122-35 [PubMed]
Kitabchi (2001) Diabetes Care 24:131-53 [PubMed]
Kitabchi (2004) Diabetes Care 27(suppl 1): S94-102 [PubMed]
Trachtenbarg (2005) Am Fam Physician 71: 1705-22 [PubMed]
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