Diabetes Ketoacidosis Patricia Arroyo Parejo Pediatrics Resident Holtz Children’s Hospital

Question A 7yo boy presents to the ED with history of polydipsia, polyuria and subjective weight loss for the past 3 weeks. He appears tired but, on physical examination, shows only mild signs of dehydration. Initial laboratory tests reveal the following results: Serum glucose 884 mg/dL (49.1 mmol/L) Serum sodium 131 mEq/L Serum potassium 4.5 mEq/L pH 6.92 on arterial blood gas

Of the following, the MOST important first step in managing this patient is to administer: An insulin drip, beginning at 0.1 units/kg/hr An intravenous insulin bolus of 0.1 units/kg Lactated ringer solution 20mL/kg over 15 min Normal saline 10-20mL/kg over 1-2 hours Sodium bicarbonate 1-2 mmol/kg over 60 min

According to the American Diabetes Association and Pediatrics endocrine Society recommend initial management with a bolus of isotonic fluids, typically 10-20mL/kg over 1 to 2 hours. The reason to give the bolus slowly is to prevent a rapid decrease in glucose concentration because this may be one of many risk factors for the development of cerebral edema. Other options: Insulin therapy is recommended to be started 1 to 2 hours after fluid resuscitation has begun. IV sodium bicarbonate should not be used in the routine treatment of DKA in children.

IV Sodium Bicarbonate In children with DKA and: - pH < 6.9 to 7.1 - evidence of hemodynamic instability - life-threating hyperkalemia IV Sodium bicarbonate can be used, although there are well- recognized risks with this treatment like: Paradoxical CNS acidosis Hypokalemia Increased risk of cerebral edema

Question A 4yo boy with DM 1 presents to the ED, parents report that they have been having troubles controlling his glucose over the past few days. The patient looks mild dehydrated but otherwise his physical examination is unremarkable. Laboratory results shows: - Serum glucose 930 - Serum bicarbonate 11 - pH 7.1 on arterial blood gas UA ketones > 160 Glucose >2000 He is diagnosed with a diabetic ketoacidosis and treatment is initiated immediately.

He receives a normal saline bolus 10mL/kg over 1 hour Fluid deficit calculated at 9% and maintenance fluids are initiated Planned to initiate an insulin drip as soon as patient is admitted at the PICU 6 hours after treatment is initiated parents report that the patient is irritable and has been complaining of severe headache. He had one episode of non bilious non bloody emesis and vitals signs are unstable showing elevated BP and slightly decreased HR The MOST important following step in managing this patient is:

Increased fluids to 1.5 maintenance rate Start IV sodium bicarbonate Start Mannitol IV 0.25-1 g/kg over 20 minutes Stop insulin pump and check glucose Consult neurology Cerebral edema occurs in approx 1% of children with DKA and has a high mortality rate up to 24%. Early diagnose and treatment can prevent up to ~80% mortality.

Bedside evaluation of neurologic state of children with DKA Minor criteria - Headache - Vomiting - Altered mental status (irritability, lethargy) - Elevated BP Major criteria - Deteriorating mental status - Incontinence - Changes in pupillary response or other cranial nerves - Inappropriate slowing heart rate - Increased serum sodium concentration - Decreased O2 Saturation - Abnormal neurogenic respiratory pattern

References Current Pediatrics Diagnosis and Treatment, 22nd Edition Up to date: “Treatment and complications of diabetic ketoacidosis in children” Authors: George S, Jeha, MD; Morey W, Haymon, MD ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WW, Mungai LN, Rosenbloom AL, Sperling MA, Hanas R, International Society for Pediatric and Adolescent Diabetes. Pediatr Diabetes. 2014;15 Suppl 20:154. Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA. www.pem-jackson.com www.pedialink/aap/org Canadian Medical Association Journal: Diabetic ketoacidosis and pediatric stroke: teaching case report. 2005 Feb 1; 172(3): 327–328. Josephine, Ho; Danielle Pecaud;

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