Pediatric Conference 4/4/12 Follow Up: DKA Management Clinical Pearls
DKA in Pediatrics: DKA occurs when there is a disruption in the balance between insulin and counter-regulatory hormones secondary to a deficiency in circulating insulin. The resulting state is hyperglycemia, hyperosmolarity, increased lipolysis, ketonemia and metabolic acidosis.
Diagnostic criteria include
Major: Hyperglycemia, Venous pH less than 7.3 or bicarbonate less than 15 mmol/L
Minor: Glycosuria, ketonuria and ketonemia
Presentation:
DKA will present with dehydration, Kussmaul breathing, severe abdominal pain, nausea and vomiting.
Patients may have fever if infection is also present.
Management:
Fluids:
Isotonic fluid administration of 10 to 20cc/kg over 1-2 hours
The remainder should be given evenly over at least 48 hours
Fluid infusion should not exceed a rate of 1.5 to 2 times the usual daily requirement.
Urinary losses should not be added to the calculation of replacement fluids
Insulin:
Bolus of insulin is controversial
Dose should be maintained at 0.1 U/kg/h until resolution of ketoacidosis.
Glucose should be added to intravenous fluid when the plasma glucose falls to 250 to 300
Electrolytes:
Replace potassium once the serum levels are no longer elevated and the patient has urinated
Phosphate deficit can also occur but studies show no significant clinical benefit for phosphate replacement in DKA, you can use potassium phosphate for replacement of both potassium and phosphate.
Use of bicarbonate, is controversial and can be considered with pH less than 6.9 for those who have impaired cardiac contractility, peripheral vasodilatation, poor tissue perfusion and life-threatening hyperkalemia.
Cerebral Edema:
Make sure you recognize it early
Elevate the head of the bed
Reduce intravenous fluids
Give Mannitol or 3% NS to reduce intracranial pressure
Infection:
Often DKA can present because the patient has an underlying infection.
Antibiotics can be given if there is clinical suspicion
Remaining controversies in this case :
Can you use succinylcholine to intubate children with children with DKA?
Succinylcholine should not be used if you have a concern for hyperkalemia.
In this case you would expect a hyperkalemia with someone in DKA, although systemic hypokalemia is expected, serum hyperkalemia is likely in those with DKA.
You can use succinylcholine for those with suspected cerebral edema, there is no contraindication. You can also elect to use fentanyl and lidocaine before intubation.
Succinylcholine can cause a rise in intraocular pressure which is minimal 3-8 mm Hg, The act of direct laryngoscopy will increase IOP significantly more that that. Blinking can increase IOP 10-15mm Hg.
Atropine was used in this case during intubation due to bradycardia, so when is atropine used during intubation?
Airway manipulation and succinylcholine can cause bradydysrhythmias in children. The mechanism is thought to be the binding of succinylcholine to postganglionic muscarinic receptors on the vagus nerve or by direct stimulation by direct laryngoscopy. Atropine(0.01mg/kg-0.02mg/kg up to 1mg) prophylaxis when using succinylcholine is considered standard, especially in children younger than 7 year of age. Rocuronium was used this case and bradycardia is thought to have been due to airway manipulation.
When can we use Sodium Bicarbonate to treat acidosis?
Bicarbonate can be used judiciously but only if the academia is affecting cardiac contractility or if there is life-threatening hyperkalemia(along with other interventions). Some studies state that administration of bicarbonate can cause increased intracellular acidosis if given and can worsen the clinical outcome for those with DKA.
Please post any additional topics of debate and feel free to comment on any aspect of the case.
References
Klein M, Sathasivam A, Novoa Y, Rapaport R. Recent consensus statements in pediatric endocrinology: a selective review. Endocrinol Metab Clin North Am. 2009 Dec;38(4):811-25.
Kovarik WD, Mayberg TS, Lam AM, Mathisen TL, Winn HR. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg. 1994 Mar;78(3):469-73.
Gaglia JL, Wyckoff J, Abrahamson MJ. Acute hyperglycemic crisis in the elderly. Med Clin North Am 2004;88(4):1063-84.
Lafferty, K et al. Medications used in Tracheal Intubation http://emedicine.medscape.com/article/109739-overview#aw2aab6b7. May 16 2011
Richard.Shin
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Great review Rich. The stuff you brought up about potassium is important because the K+ swings can be fatal. Never give insulin until you see the potassium level. If you are starting out low due to wash-out from excessive osmotic dieresis, you risk making the patient hypokalemic enough to cause arrhythmias that may not be easily terminated by traditional ACLS protocols.