1. Management of Diabetic Ketoacidosis in the PICU
PICU Resident Lecture Series

2. DKA - A common PICU diagnosis
Incidence 4.6 – 8 per 1000 person years among people with diabetes
Pediatric mortality rate is 1-2%

3. DKA causes profound dehydration
Hyperglycemia leads to osmotic diuresis
Often 10-15% down from baseline weight
Profound urinary free water and electrolyte loss
Free water follows glucose into urine
Electrolytes follow free water into urine

4. Electrolyte abnormalities
Pseudo-hyponatremia with hyperglycemia
Sodium should rise with correction of glucose
Profound total-body K+ depletion
Urinary loss, decreased intake, emesis
Initial K+ may be high due to acidosis, low insulin
Aggressive K+ replacement necessary to prevent arrhythmias
Phosphate, magnesium, calcium require replacement

5. Initial DKA management - ED
Resuscitation aimed at shock reversal
Begin with mL/kg NS bolus, may repeat if signs of shock persist
Bolus fluids only necessary if signs of shock present
Avoid overly-aggressive fluid resuscitation
Concern for inciting cerebral edema, though no clear data

6. Initial DKA management - ED
NEVER give bicarbonate
Increases risk of cerebral edema
Begin insulin infusion at 0.1 units/kg/hr
Should be initiated prior to leaving ED
SQ or bolus insulin not indicated

7. Pre-PICU arrival
Order several bags of dextrose-containing and non-dextrose-containing IVF pre-PICU arrival
Often takes pharmacy 1 hour to custom-make IVF
No dextrose-containing fluids stocked in PICU

8. Fluid Management - PICU
3 components to replacement fluids
Deficit (often 10-15% total body water deficit)
Ongoing losses (polyuria, emesis)
Maintenance
Possible to calculate the above, or give:
1.5X maintenance if moderately dehydrated
2X maintenance if severely dehydrated

9. Initial IVF Isotonic fluid with potassium
NS + 20 mEq/L KCl + 20 mEq/L KPhos
Start with 40 mEq/L of potassium if K+ < 5
K+ often split between KCl and KPhos to avoid hyperchloremic metabolic acidosis
NS preferred to help prevent cerebral edema

10. Adding dextrose Add dextrose to IVF when glucose < 300
2 bag system allows titration of dextrose based on glucose
Bag 1: NS + 20 KCl + 20 KPhos
Bag 2: D10 NS + 20 KCl + 20 KPhos

11. Titrating dextrose 2 bag system example: Total IVF rate = 160 mL/hr
Fingerstick glucose = 280
Bag 1: NS + 20 KCl mL/hr
Bag 2: D10 NS + 20 KCl mL/hr
Fluids “Y” together, dextrose concentration = D2.5

12. Titrating dextrose 2 bag system example: Total IVF rate = 160 mL/hr
Fingerstick glucose = 180
Bag 1: NS + 20 KCl mL/hr
Bag 2: D10 NS + 20 KCl mL/hr
Fluids “Y” together, dextrose concentration = D7.5

13. Frequent lab monitoring is essential in DKA
Glucose q1 hour
Chem 10 , VBG q4 hours
To correct venous pH to arterial pH, add 0.04
Serial UAs to monitor for resolution of glucosuria and ketonuria

14. DKA vs. Hyperglycemic Hyperosmolar Syndrome (HHS)
HHS more likely in older, obese patients with Type II DM
Lab features of HHS
More severe hyperglycemia than DKA
Less severe or absent acidosis
Trace or absent ketones in urine
Can have normal serum bicarb
Serum osmolality > 320

15. Importance of Insulin
Insulin is the only therapy that corrects the underlying pathophysiology in DKA
Increase dextrose as necessary to continue insulin infusion at 0.1 units/kg/hr
Do NOT titrate insulin drip

16. Transitioning to SQ insulin
May consider transition when:
Bicarb > 18, pH > 7.3, AG <12, GCS 15, emesis resolved
How to transition – order of events:
Fingerstick glucose pre-meal  eat meal  give SQ insulin  stop drip
May re-check VBG post-meal to ensure that acidosis has not recurred

17. Complications of DKA Cerebral Edema
Vasogenic vs. cytotoxic, unclear etiology
Risk factors:
Age <5 years
High BUN (severe dehydration)
Severity of acidosis
Bicarbonate administration
New-diagnosis diabetes
Na levels don’t rise as expected with treatment

18. Cerebral Edema Hourly neuro / pupillary checks
Mannitol 0.5 g/kg at bedside
Consider 3% NaCl bolus 3-5 mL/kg if Na drops with therapy
Stat head CT for any concerning mental status changes
Give mannitol prior to going to CT!
If CT reveals cerebral edema and GCS is <8, consult neurosurgery for ICP monitoring

19. Complications of DKA Thrombosis ARDS Dehydration, low flow state
Avoid central lines if possible
ARDS
Rapid fluid resuscitation with low albumin at baseline  capillary leak, pulmonary edema
Rare complication in pediatric DKA

20. Complications of DKA Hyperchloremic metabolic acidosis Hypoglycemia
May check urine for ketones if unsure whether DKA has resolved
Hypoglycemia
Rare with appropriate dextrose titration
Hypokalemia
Can lead to fatal arrhythmias
K+ must be repleted aggressively

21. 10 Tips for Managing DKA in PICU
2 large-bore PIVs
Frequent lab monitoring
Hourly neuro checks
Watch for falling sodium
Correct hypokalemia aggressively
NEVER give bicarb
Do NOT titrate insulin drip
Mannitol to bedside
Order IVF pre-PICU arrival
Search for underlying cause (infection, non-compliance, etc.)