Diabetic Ketoacidosis – remember in paediatrics this may be the 1st presentation of diabetes.
- Fluid – are more considered that adults due to the risk of cerebral oedema
- Insulin – WAIT – need 1hr of fluid first
- Paeds – involve them early
Confirm DKA
Clinical
- Acidotic Respiration
- Dehydration
- Drowsy [Monitor mental state hourly]
- Abdominal Pain/Vomit
Biochemical
- Blood Glucose >11mmol/l
- Blood pH <7.3 &/OR HCO3 <18mmol/l
- Blood Ketone >3mmol/l
- Glucose & Ketones in Urine
Investigations
- Blood Glucose
- U&E
- FBC
- Venous/Capillary Gas
- Blood Ketone
- 0 – 0.5 [Negative – Low]
- 0.6 – 1.5 [Low – Moderate]
- 1.6 – 3 [Moderate]
- >3 [High]
- Chloride, Calcium, Phosphate
- Consider Blood cultures (fever is not part of DKA)
Assess Dehydration
[Overestimation is dangerous, Maximum of 10% in calculations]
- Mild-Moderate 5% – pH of 7.1 or higher
- Severe 10% – pH less than 7.1
- Shock – Only ONE 10ml/kg 0.9% NaCl bolus should be given, without senior input.
Fluid Boluses – should only be 10ml/kg 0.9% NaCl
Fluid – too much is dangerous
- Use: 0.9% NaCl + 20mmol KCl (500ml)
Deficit Calculation (ml) = % dehydration x Weight[kg] x 10
-
- 5% dehydration = 50ml/kg/48hr,
- 10% dehydration = 100ml/kg/48hr
- Replace over 48 hours
- Take boluses off total
Maintenance
- under 10kg – 2ml/kg/hr
- 10 to 40kg – 1ml/kg/hr
- over 40kg – fixed 40ml/hr
[NICE 2015 – maintenance reduced to help avoid Cerebral Oedema]
Blood Glucose under 14mmol/l
- Use: 0.9% NaCl + 20mmol KCl + 5% dextose
Sodium Correction – D/W Paeds senior
Insulin
- ONLY Start more than 1hr after fluid
- There is no need to start in ED [unless prolonged stay]
- Evidence: Early insulin increases likelihood of Cerebral Oedema
USE: 50 unit Actrapid in 49.5ml 0.9% NaCl [Syringe pump must be used]
Dose
- Insulin infusion – 0.05unit/kg/hour (0.05ml/kg/hour)
- Blood Glucose <14mmol/l – change fluid 0.9% NaCl + 20mmol KCl + 5% dextrose
- Blood Glucose <4mmol/l – Bolus 2ml/kg 10% dextrose
- Blood Glucose not falling – Consider increase to 0.1unit/kg/hr [D/W Paeds]
BSPED Fluid Calculator:BSPED fluid calculator
PDF:dkap
