DKA in Kids

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

 

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