1. Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)
Presentation title
Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)
In this session we shall cover aspects if the emergency care of a child with diabetes

2. Programme 1 2 3 Managing DKA Treating and preventing hypoglycaemia
Slide no 2
Programme 1
Managing DKA 2
Treating and preventing hypoglycaemia 3
Surgery in children with diabetes
This session shall cover 3 aspects namely the management of diabetic ketoacisosis, treating and preventing hypoglycaemia and managing the child who has to undergo surgery.

3. Diabetic Ketoacidosis
Slide no 3
Diabetic Ketoacidosis
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
Diabetic ketoacidosis occurs when there is insufficient insulin action. DKA is commonly seen at diagnosis but may occur at any stage of diabetes. The appearance of ketones and diagnosis of DKA signifies a life threatening clinical situation for the child. The child must be transferred to the best available site of care for the management of the DKA. This site should have experience with diabetes care and with management of DKA. Arrange for transfer as soon as the diagnosis is suspected or confirmed. It is important to initiate treatment at your site prior to transfer.

4. Type 1 Diabetes Increased urine Dehydration Thirst
As a reminder from earlier today, diabetes occurs because of insufficient insulin. The result is an elevated blood glucose, increase urination, dehydration and increased thirst.

5. DKA Weight loss Ketones Shock Dehydration Nausea Vomiting
Liver
Weight loss
Ketones
Nausea
Vomiting
Abdominal pain
Altered level of consciousness
Shock
Dehydration
Muscle
Fat
Ketones
Weight loss
With breakdown of fat, ketones are produced. The presence of ketones may cause nausea, vomiting, abdominal pain and an altered level of consciousness. With worsening dehydration and acidosis, the child will develop circulatory shock. Left untreated this will cause death. Death may be the result of severe dehydration, acidosis or changes in electrolytes.

6. Pathophysiology (What’s wrong)
Slide no 6
Clinical features
Pathophysiology (What’s 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
The clinical features and their pathophysiological effect are listed on this slide. The elevated blood glucose causes polyuria and polydypsia and may be confirmed by an elevated laboratory glucose value, glucometer reading or glucose in the urine. Dehydration has similar clinical signs to dehydration from other causes. These signs include sunken eyes, dry mouth, decreased skin turgor, absence of tears and decreased perfusion. The decrease perfusion is also a sign of circulatory shock. Alterations in electrolyte levels may cause irritability and changes in the level of consciousness. The appearance of ketones causes acidosis and the clinical signs of include rapid or acidotic breathing, nausea, vomiting, abdominal pain and an altered level of consciousness.

7. Managing DKA Refer to best available site of care whenever possible
Slide no 7
Managing DKA
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
As a reminder, again DKA is a life threatening event. Therefore, the child must be transferred to the best available site of care for the management of the DKA. This site should have experience with diabetes care and with management of DKA. There should be laboratory support and appropriate nursing expertise. Arrange for transfer as soon as the diagnosis is suspected or confirmed. It is important to initiate treatment at your site prior to transfer. Written guidelines for the management of DKA should be available at all heath care facilities. Ensure that your centre has these guidelines available.

8. DKA monitoring form

9. DKA monitoring
DKA protocol available to the clinic

10. Principles of DKA management (1)
Slide no 10
Principles of DKA management (1)
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
There are a number of different steps in the management of DKA. In order, these are the correction of the shock, rehydration of the patient, correction of the hyperglycaemia, correcting and preventing electrolyte abnormalities. Correction of acidosis is rarely needed but needs consideration. Infection is a common cause of presentation with DKA and may require treatment. Complications of DKA are rare but can be fatal or cause long term neurological deficits.

11. Principles of DKA Management (2)11
Slide no 11
Principles of DKA Management (2)
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
On completion of the resuscitation, you need to move onto the next step which is correcting the dehydration.
Make sure that the child is adequately resuscitated before proceeding. This includes having good perfusion and a stable haemodynamic circulation, but it is not necessary to correct the level of consciousness before proceeding.

12. Principles Correction of shock Correction of dehydration12
Slide no 12
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
Having corrected the shock and obtained a stable haemodynamic status, you can start to correct the dehydration. During this period you can start to correct the high blood glucose levels. In other words start correction the dehydration and the high glucose values at the same time.

13. Assessment History and examination including: Determine weight
Slide no 13
Assessment
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
Prior to initiating treatment, you need to assess the patient. Assessment starts with a history and examination. It is particularly important to assess the severity of the dehydration as this determines your management. If you uncertain, assume that the patient is 10% dehydrated. The level of consciousness is also an important aspect of the examination. Determine the patients weight whenever possible. Measure the blood glucose with a glucometer or laboratory glucose and determine level of ketones in the urine. If a laboratory is available on site, carry out the following tests: blood glucose, urea and electrolytes, haemoglobin, white cell count, HbA1c. Take appropriate microbiological samples if infection is suspected. If no laboratory is available, take the appropriate samples and send with the patient to the next level of care.

14. Slide no 14
Resuscitation (1)
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
The first step in the management of the child is resuscitation of the shocked or critically ill child. This must start as soon as the assessment has revealed a shocked or critically ill child.
Ensure appropriate life support, that is, the ABC of paediatric resuscitation. Make sure that there is an adequate airway and that the child is breathing. Support breathing by bagging and artifical ventilation. Give oxygen to children with impaired circulation and/or shock.
Set up a large IV cannula. If IV therapy is not available at the site, set up intra-osseous access.
Treat shock (decreased perfusion) with fluid intra-venous or through an intra-osseous line. Use normal saline or Ringers lactate at 10ml/kg over 30 minutes. Repeat boluses of 10ml/kg until perfusion improves.

15. Slide no 15
Resuscitation (2)
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
If an IV or intra-osseous line is not available, place a nasogastric tube. Transfer child to a site with IV facilities as soon as possible.
Start replacing fluid at 10 mls per kg and replace this volume over 60 minutes. Use normal saline, half-strength Darrows solution with dextrose, or oral rehydration solution and continue fluid replacement until the perfusion improves.  If the child is vomiting repeatedly, decrease rate to half of the previous rate. Tranfer to site with facilities for intravenous fluid replacement as soon as possible. Continue replacing fluid during the transfer!

16. Principles Correction of shock Correction of dehydration16
Slide no 16
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
Having corrected the shock and obtained a stable haemodynamic status, you can start to correct the dehydration. During this period you can start to correct the high blood glucose levels. In other words start correction the dehydration and the high glucose values at the same time.

17. Rehydration (1) Rehydrate with normal saline
Slide no 17
Rehydration (1)
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 <15 mmol/l, add dextrose to the saline (add 100 ml 50% dextrose to every litre of saline, or use 5% dextrose saline)
Children with DKA are resuscitated with normal saline. Provide fluids equal to the maintenance and for the degree of dehydration. If you are uncetrtain about the degree of dehydration, assume dehydration to be 10%. Replace this fluid volume over 48 hours. It is safer to rehydrate slowly rather than too rapidly. As a rule of thumb, the sicker the child the slower the rehydration.
When calculating fluid replacement, do not add the urine output to the replacement volume. Reassess clinical hydration regularly.
Once the glucose is less than 15 mmol/l, add dextrose to the IV fluids. This could be done by adding 100 mls of 50% dextrose to each litre of saline or you could use 5%drextrose saline. Once the blood glucose is <15 mmol/l, add dextrose to the saline (add 100 ml 50% dextrose to every litre of saline, or use 5% dextrose saline).

18. Rehydration (2) If IV/intra-osseous access is not available:
Slide no 18
Rehydration (2)
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
If intravenous/osseous access is not available, rehydrate orally with oral rehydration solution (ORS). This can be done by nasogastric tube at a constant rate over 48 hours. If a nasogastric tube is not available, give ORS by oral sips at a rate of 1ml/kg every 5 minutes. Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible. 

19. Principles Correction of shock Correction of dehydration
Slide no 19
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications
Having corrected the shock and obtained a stable haemodynamic status, you can start to correct the dehydration. During this period you can start to correct the high blood glucose levels. In other words start correction the dehydration and the high glucose values at the same time.

20. Slide no 20
Insulin therapy (1)
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
Start insulin therapy only after circulation has been restored and the patient is haemodynamically stable.
The best way to correct the high blood glucoses is to start an insulin infusion of short acting insulin (Actrapid). Deliver insulin at 0.1u/kg/hour. This rate should be controlled with the best available technology (infusion pump). For example, a 14 kg child should receive 1.4u/hour of Actrapid. If you put in a dose equivalent to body weight into 100 mls of saline, then an infusion rate of 10mls per hour will deliver 0.1 u/kg/hour.

21. Insulin therapy (2) Example:
Slide no 21
Insulin therapy (2)
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 U/kg/hour
In children under 3 years of age, consider using a lower rate on insulin delivery e.g. 0.05u/kg/hour.
Do not correct glucose too rapidly; aim for a glucose reduction of about 5 mmol/l per hour. A more rapid decline may contribute to the development of cerebral oedema. If glucose declines very rapidly, decrease the rate of insulin delivery.

22. Slide no 22
Insulin therapy (3)
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
If no suitable control of the rate of the insulin infusion is available, or if you are not to gain intravenous access, use sub-cutaneous or intra-muscular insulin. Give 0.1 u/kg of Actrapid sub-cutaneously or IM into the upper arm. 
Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible. 
Important: the presence of ketones suggests inadequate insulin delivery. Continue giving insulin IV or hourly until ketones have been cleared.

23. Principles Correction of shock Correction of dehydration
Slide no 23
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications

24. Electrolyte deficits The most important is potassium
Slide no 24
Electrolyte deficits
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

25. ECG and Potassium Levels
Alterations in potassium levels can be reflected in the ECG tracings with

26. Potassium (1) Levels determined by laboratory test
Slide no 26
Potassium (1)
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

27. Slide no 27
Potassium (2)
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

28. Monitor serum potassium 6-hourly, or as often as is possible
Slide no 28
Potassium (3)
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

29. Principles Correction of shock Correction of dehydration
Slide no 29
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications

30. Acidosis Usually due to ketones Poor circulation will make it worse
Slide no 30
Acidosis
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

31. Principles Correction of shock Correction of dehydration
Slide no 31
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications

32. Infection Infection can precipitate the development of DKA
Slide no 32
Infection
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

33. Principles Correction of shock Correction of dehydration
Slide no 33
Principles
Correction of shock
Correction of dehydration
Correction of hyperglycaemia
Correction of deficits in electrolytes
Correction of acidosis
Treatment of infection
Treatment of complications

34. Complications Electrolyte abnormalities Cerebral oedema
Slide no 34
Complications
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

35. Cerebral Oedema (1) Presents with
Slide no 35
Cerebral Oedema (1)
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

36. Cerebral Oedema (2) Check blood glucose
Slide no 36
Cerebral Oedema (2)
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 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

37. Slide no 37
Monitoring
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

38. DKA – In Summary Life threatening condition
Slide no 38
DKA – In Summary
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
So, to summarize. DKA is a life threatening condition. Because of numerous, rapidly changing variable, it requires care at the best available facility. Morbidity and mortality from DKA can be reduced by early treatment. In particular, early adequate hydration and active management of the shock are crucial any may be life saving. Written guidelines should be available at all levels of the healthcare system, including in your clinics.

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