No Bullus Paediatric DKA
Resident Clinical Pearl – December 2016
Luke Taylor, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
An altered 2yr old female child presents to your Emergency Department with a BP of 80/50 and a ++high point-of-care blood glucose…….anxiety provoking for all concerned right?
With a presentation like this, the best thing to do according to the House of God…is to “check your own pulse.” Hopefully after reading this RCP you won’t need to and please don’t waste time recognising that this is severe DKA and this child needs appropriate emergency management.
Key Point – DO NOT BOLUS Fluid and DO NOT BOLUS Insulin
Paediatric DKA (P-DKA) was deemed by a TREKK (TRanslating Emergency Knowledge for Kids) Needs Assessment to be to be an area in which general EDs wished to improve management. A lack of awareness that optimum P-DKA management is different from that of adult DKA was a major driver. In particular, recognition that P-DKA can be complicated by cerebral edema in up to 1.5% of cases.
Management
Is the child in Decompensated Shock? Systolic BP less than (70+(2*age in yrs) for a child >1yr.
If Decompensated? = Bolus 5-10cc/kg over 1-2hrs and reassess after each bolus
If not Decompensated? = Correct slowly
Max fluid = 2x maintenance of Normal Saline
Time: Calculate to correct fluid deficit over 48hrs, most are 4-8% dehydrated in moderate DKA
**DKA develops over days (most of the time), therefore slow correction**
Fluid alone, over first 1-2hrs, then Fluid + insulin infusion at 0.05-0.1U/kg/hr
Cerebral Edema (CE)
Risk factors:
- <5yrs old
- new onset DM
- ++acidosis
- longer duration of symptoms
- severe dehydration
Symptoms of CE:
**Generally 3-12hrs after initiation of therapy
- headache
- vomiting
- confusion
- GCS<15
- irritability
Treatment of CE:
- ABCs
- restrict IV fluid to maintenance
- elevate head of bed
- Mannitol (0.5-1gm/kg IV over 20min) and/or 3% NaCl (5-10ml/kg IV over 30min)
Bottom line
Always:
Use paediatric specific protocol
Like this: https://sjrhem.ca/guideline/dka-pediatrics/
or http://www.bcchildrens.ca/endocrinology-diabetes-site/documents/dkaprt.pdf
And: contact local paediatric diabetes specialist
DO NOT: BOLUS
References
EM Cases Paediatric DKA: https://emergencymedicinecases.com/pediatric-dka/ (Great podcast!)
Lifeinthefastlane DKA: http://lifeinthefastlane.com/ebm-diabetic-ketoacidosis/
Diabetes Ther. 2010 Dec; 1(2): 103–120. The management of diabetic ketoacidosis in children – Arlan L. Rosenbloom
TREKK: http://trekk.ca/
