Presentation title

Emergency Care
Part 1: Managing Diabetic Ketoacidosis
(DKA)
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Programme

1 Managing DKA

2 Treating and preventing hypoglycaemia

3 Surgery in children with diabetes

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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
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Type 1 Diabetes

Increased urine
Dehydration
Thirst
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DKA

Liver
Weight loss
Ketones
Muscle Nausea
Vomiting
Fat Abdominal pain
Altered level of
consciousness
Shock
Dehydration
Ketones
Weight loss
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Clinical features
Pathophysiology Clinical features
(Whats wrong) (What do you see)

Elevated blood High lab blood glucose, glucose meter

glucose 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 Acidotic breathing, nausea, vomiting,

(ketosis) abdominal pain, altered level of
consciousness
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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
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DKA monitoring form

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DKA monitoring

DKA protocol available to the clinic

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Principles of DKA management (1)

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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Principles of DKA Management (2)

1. Correction of shock or decreased peripheral

circulation quick phase

2. Correction of dehydration - slow phase

Do not start insulin until the child has been

adequately resuscitated, i.e. good perfusion and
good circulation
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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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
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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)
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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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. 0.05 U/kg/hour
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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ECG and Potassium Levels

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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
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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
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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Principles

1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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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
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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
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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 0.5-1 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
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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
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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
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Questions
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