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DKA: Critical Care Lecture Series PICU Fellows Lecture.

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Presentation on theme: "DKA: Critical Care Lecture Series PICU Fellows Lecture."— Presentation transcript:

1 DKA: Critical Care Lecture Series PICU Fellows Lecture

2 Objectives  Review of the pathophysiology of DKA  Review of Fluid Management  Current DKA Management Guidelines  Review of Common complications  Current Protocols

3 Biochemical criteria  Hyperglycemia ~200mg/dL  Venous pH<7.3 or bicarbonate <15  Ketonemia and ketonuria

4 Pathophysiology Steel, S.

5 1 2 3

6 1 2

7 HHS vs DKA Kitabchi, A., Et Al.

8 Comparing DKA And HHS DKA  Hyperglycemia ~200mg/dL  Venous pH<7.3 or bicarbonate <15  Ketonemia and ketonuria HHS  Glucose >600  pH>7.3  Bicarbonate>15  Small ketonuria  Effective serum osmolarity >330mOsom  Stupor or coma

9 Clinical Manifestations  Dehydration  Rapid, deep sighing (Kussmaul respirations)  Nausea, vomiting and abdominal pain  Progressive obtundation and loss of consciousness  Increased leukocyte count with Left shift  Non-specific elevation of serum amylase  Fever only when infection is present

10 Severity of DKA  Mild: Venous pH <7.3 or bicarbonate <15mmol/L  Moderate: Venous pH <7.2, bicarbonate <10  Severe: Venous pH <7.1, bicarbonate <5mmol/L Stamatis P, Et al.

11 Frequency of DKA More common at diagnosis in younger children  Families who do not have access to medical care  Risk is increased in patients with:  Poor metabolic control, and previous DKA  Peripubertal and adolescent girls  Children with psychiatric disorders  Children with difficult family situations  Children who omit insulin  Insulin pump therapy

12 Clinical Assessment  Assess the Fluid Status  Assess the degree of consciousness

13 Challenges in the ER  Accurate fluid assessment of these children is difficult  Urine OP is obscured  Inevitably tachycardic  Kussmal respirations  History of the type of fluid to rehydrate is extremely important as well

14  Prospective consecutive case series  Percentage loss of weight  Parents weight at presentation, inpatient discharge, and first follow-up clinic visit were used to calculate percent loss of body weight  33 episodes of DKA  Patients had moderate DKA 4-8%  67% of patients in their study were assessed to be severely dehydrated when only 12%, using percent loss of body weight

15 Biochemical Assessment  Obtain plasma glucose, electrolytes, osmolarity, venous pH, pCO2, calcium, phosphorus and Magnesium, HbA1C, CBC  UA  B-hydroxybutyrate  Potassium  Cultures

16 Goals of Therapy  Correct Dehydration  Correct acidosis and reverse ketosis  Restore blood glucose to near normal  Avoid complications of therapy  Identify and treat precipitating event

17  Retrospective cohort study  Use of rehydration fluids with higher sodium content would positively influence natremia possibly reducing the incidence and severity of cerebral edema  Found that increases in sodium were an independent predicting factor against brain edema  Issues: Hypernatremia, change to hypotonic fluids hours after admission


19 Wolfsdorf et al. Initial Fluid Management

20 Fluids  Replace deficit for next 4-6 hours with NS or LR  Can change fluids to ½ NS or a fluid of greater tonicity if the physician deems this necessary  The goal is then to rehydrate evenly over 48 hours

21  Extremely common during treatment  Two PICUs, Liverpool and London  Retrospective Chart review  Incidence of hyperchloremia increased from 6% to 94% over 20 hours of treatment  Base deficit decreased over treatment time however proportion due to hyperchloremia increased from 2-98%

22 An Example Calculation..  Body weight in kilograms  Establish extent of dehydration  InfantsChildren  Mild: 5% = 50 ml/kg 3% = 30 ml/kg  Moderate:10% = 100 ml/kg 6% = 60 ml/kg  Severe: 15% = 150 ml/kg 9% = 90 ml/kg

23 An Example Calculation  Calculate maintenance fluid requirements for the next 48 hours:  200 ml/kg for the first 10 kg body weight  ml/kg for the next 10 kg  + 40 ml/kg for the remaining kg  Calculate the total amount of fluid to be given for our patient over the next 48 hours

24 More Fluid Calculations…  Maintenance plus your deficit will equal what you need to give over 48 hours  Divide that number by 48 hours

25 Two Bag Method Metzger DL.

26 Two Bag Method  Glucose > 350 mg/dl: Run NS + additives at 100% of calculated rate  Glucose 250 – 350 mg/dl: Run NS at 50% rate, run D10 NS at 50% rate  Glucose < 250 mg/dl: Run D10 NS + additives at 100% rate

27 Insulin therapy  To be started after our initial fluids after the first 1-2 hours in DKA  If given before this it has been shown in a case control study in the UK to have a 12 fold increased risk of cerebral edema  Dose: 0.1 unit/kg/hour Woldfsdorf, J. Et Al.

28  20 episodes of DKA in 19 children  Bolus group and no bolus group  Significantly lowers glucose in first hour  “osmotic disequilibrium”  Precipitous drop in blood glucose Fort, P. Et al.

29  38 children with 56 episodes of DKA  No statistically significant different change in serum glucose, osmolarity

30 Potassium  Total body potassium deficits  Major losses from the Intracellular space  May be normal on presentation  Potassium  Hypokalemic  Normal potassium  Hyperkalemic Woldfsdorf, J. Et Al.

31 Acidosis  Severe acidosis reversible by fluid and insulin replacement  Stops further ketoacid production  Allows ketoacids to be metabolized  Bicarbonate administration may cause paradoxical CNS acidosis(Hale, Pj., Et Al.)

32  Retrospective consecutive case series  Initial pH 300  106 children in 16 yr time period, at tertiary university medical centers  57 treated with bicarb  No improved clinical outcome with adjunctive bicarbonate therapy  Possible longer hospitalization for the patients who received the bicarb Green, SM. Et al.

33 Mortality and Morbidity  Cerebral edema accounts for 75-87% of all DKA deaths(Nichols, D. Et Al.)  10-25% have significant residual morbidity  Other complications  Electrolyte abnormalities  DIC, Dural Sinus Thrombosis  Sepsis

34 Carlotti A P C P et al. Arch Dis Child 2003;88:

35 Late risk factors for the development of cerebral oedema. Carlotti A P C P et al. Arch Dis Child 2003;88:

36  2001, multicenter study  Children <18 yr  61 children with CE  181 randomly selected with DKA  174 match to the CE group  Using logistic regression, they found that lower CO2 and higher BUN, and children treated with bicarbonate Glaser, Nicole, Et al.

37 Cerebral Edema Diagnostic criteria o Abnormal motor or verbal response to pain  Decorticate or decerebrate posture  Cranial nerve palsy  Abnormal neurogenic respiratory pattern

38 Cerebral edema Major  Altered mentation/fluctuatin g level of consciousness  Sustained heart rate deceleration-not from improved volume or sleep  Age inappropriate incontinence Minor  Vomiting  Headache  Lethargy or difficult to rouse  Diastolic blood pressure >90mmHg  Age <5yrs One diagnostic, Two major, or one major and one minor have a sensitivity of 92%

39 Treatment of cerebral edema  Reduce fluid volume by 1/3  Mannitol 0.5-1gm/kg  Hypertonic saline 5-10ml/kg (alternative or second line therapy)  Intubation if impending respiratory failure, aggressive hyperventilation  Elevate the head of the bed  Then---CT to rule out thrombosis or other intracerebral causes

40  Retrospective Observational study, in Royal Children’s Hospital In Melbourne  67 children with DKA  Were in two groups equally distributed  Plasma osmolarity had a more gradual reduction in the 0.05u/kg/hr group  Younger children  Further research as whether this may reduce the risk of cerebral edema Hanshi, S, Et Al.l

41 Protocolized approach  Minimizes risks for young children with DKA especially for Cerebral Edema  ISPAD guidelines are currently the gold standards internationally Woldfsdorf, J. Et Al.

42 Protocols, protocols, protocols….

43 Additional Protocols

44 Nursing Flowsheets

45 Consensus Statements

46 In Summary  Caution use of Hypotonic fluids in the first hours of DKA management  Assess the ECF contraction  Increased attention to serum sodium levels and Chloride levels  Delay in the introduction of insulin infusions  Protocols

47 Thank you! Any Questions?

48 References  British Columbia DKA Toolkit. January 8,  Cefalu W. Diabetic Ketoacidosis. Critical Care Clinics 7(1): ,  Carlotti A P C P et al. Arch Dis Child 2003;88:  Jeha, G, Et al. Treatment and Complication of Diabetic Ketoacidosis in children. Uptodate. September  Kawamata,,T, Et At. Tissue Hyperosmolality and Brain Edema in Cerebral Contusion. Neurosurg Focus. 2007;22(5):E5 © 2007 American Association of Neurological Surgeons.  Kitabchi, A. Et Al. Hyperglycemic Crices In Patients with diabetes: DIiabetic Ketoacidosis (DKA), and Hyperglycemic Hyperosmolar State  Fort, P., Et Al. Low Dose insulin infusion in the the treatment of diabetic ketoacidosis: bolus versus no bolus. The journal of Pediatrics. January  Glaser, Nicole, Et al. Risk Factors for Cerebral Edema in Children with Diabetic Ketoacidosis. NEJM. Volume 344, No. 4, Jan. 25,  Green SM., Et Al. Failure of Adjunctive Bicarbonate to improve outcome in severe Diabetic Ketoacidosis Ann Emerg Med Jan: 31(1):  Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed) 1984 Oct 20: 289(6451): 1035 – 8.  Hanshi, S, Et Al. Insulin infusion at 0.05 versus 0.1 unit/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatric Critical Care Medicine 2011 Vol 12, no

49 References  Metzger, D. Diabetic Ketoacidosis in children and adolescents: an update and revised treatment protocol. BC Medical Journal. Vol. 52. no 1, Jan/Feb  Nicols, D. Disorders of glucose homeostasis. Rogers’ Textbook of Pediatric Intensive Care :  Orlowski, james., Et al. Diabetic Ketoacidosis in the Pediatric ICU. Pediatric Clin N Am 55 (2008)  Steel, S., Et al. Contin Educ Anaesth Crit Care Pain (2009) 9 (6): doi: /bjaceaccp/mkp034  Taylor, D., Et Al. The influence of hyperchloraemia on acid base interpretation in diabetic ketoacidosis. Intensive Care medicine. (2006) 32:  Toledo, J., Et al. Sodium Concentration in rehydration Fluids for children with ketoacidotic Diabetes: Effect on serum Sodium Concentration. J Pediatr 2009;154:  Woldfsdorf, J. Et Al. Diabetic Ketoacidosis in children and Adolescents with Diabetes. Pediatric Diabetes. 2009:10(suppl. 12):  Zeitler, P. Et al. Hyperglycemic Hyperosmolar Syndrome in Children: Pathophysiological Considerations and suggested guidelines for treatment. The Journal of Pediatrics. Vol 158, P January 2011.

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