Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

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Emergency CarePart 1 Managing Diabetic
Ketoacidosis (DKA)
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Slide no 2
Programme
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Managing DKA
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Treating and preventing hypoglycaemia
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Surgery in children with diabetes
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Diabetic Ketoacidosis
Slide no 3

• 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
• Shock
• Dehydration

Muscle
Fat
Ketones
Weight loss
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Clinical features
Slide no 6
Pathophysiology (Whats 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
Slide no 7

• 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)
Slide no 10

• 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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Principles of DKA Management (2)
Slide no 11

• Correction of shock or decreased peripheral
  circulation quick phase
• 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
Slide no 12

• 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
Slide no 13

• 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)
Slide no 14

• 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)
Slide no 15

• 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
Slide no 16

• 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)
Slide no 17

• 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 lt15 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)
Slide no 18

• 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
Slide no 19

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications

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Insulin therapy (1)
Slide no 20

• 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)
Slide no 21

• 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)
Slide no 22

• 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
Slide no 23

• 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
Slide no 24

• 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)
Slide no 26

• 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)
Slide no 27

• 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)
Slide no 28

• 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
Slide no 29

• 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
Slide no 30

• 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
Slide no 31

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications

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Infection
Slide no 32

• 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
Slide no 33

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications

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Complications
Slide no 34

• 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)
Slide no 35

• 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)
Slide no 36

• 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
Slide no 37

• 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
Slide no 38

• 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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(No Transcript)