DIABETES KETO ACIDOSIS, DKA IN CHILDREN.

DIABETES KETO ACIDOSIS, DKA IN CHILDREN - EPIDEMIOLOGY, ETIOPATHOGENESIS, DIAGNOSIS AND TREATMENT

1. Prof. Dr CHAKRADHAR
MADDELA
MSc Neonatal Med Cardiff
FC Neonatology
MD Ped DCH PGD 2D ECHO CD
FC Cardiology
Consultant Neonatologist
Pediatric Sub-specialist
Diabetes keto acidosis in
children
Teaching tutorial

2. Aetiology
•Absolute or relative insulin deficiency
•ELEVATED COUNTER INSULIN REGULATORY HORMONES LIKE GLUCAGON,
CORTISOL, CATECHOLAMINES & GH
•INSULIN OMISSION –INADVERTENT OR VOLUNTARY
•LOWER DOSES OF INSULIN
•POOR PT ADHERENCE TO TREATMENT AND FOLLOW UP
•STRESS-PHYSICAL / EMOTIONAL
•INTERCURRENT INFECTIONS

3. Epidemiology
•Incidence 4.6 to 8.0 cases / 1000 diabetic persons / year
•SHH incidence is <1 per 1000 diabetics / year
•Mortality is same over many years
•Mortality depends on age of the child
•Poor prognosis at extremes of age esp with hypotension & COMA
•MORTALITY IN DKA 3.4 –4.6 %
•Seen at all ages, sex & races
•Frequently seen in children, adolescents, pregnant women

6. Biochemical
changes
Responsible for clinical
manifestations

7. Symptomatology
PAST H / OHYPERGLYCAEMIA: POLYDIPSIA & POLYURIA
NAUSEA, VOMITING, ASTHENIA, ANOREXIA & ABD PAIN
LOSS OF WT, PECULIAR BREATH & GEN MALAISE
DEHYDRATION
ACIDOTIC BREATHING
HYPOVOLEMIA
ALTERED SENSORIUM
POLYURIA POLYDIPSIA
HEMODYNAMIC DETERIORATION
SHOCK & COMA

8. Risk factors for DKA precipitation

9. Diagnostic criteria -biochemical
❑HYPERGLYCAEMIA >200mg / fl
❑KETOSIS
❑METABOLIC ACIDOSIS PH <7.30
❑BICARBONATE <15 mew / L
❑DEHYDRATION WITH WATER & ELECTROLYTE
DEPLETION

10. SEVERITY OF DKA
•MILD: Venous pH < 7.3 or bicarbonate <15 meals / L
•MODERATE: pH < 7.2 /Bicarbonate < 10 med / L
•SEVERE : pH < 7.1 & Bicarbonate < 5mEq / L

11. Investigations
Sr Na Levels
SR K Levels
ABG
BICARBONATE LEVELS
RENAL FUNCTIONAL TESTS
KETONES
ECG
CARDIAC MONITORING
BLOOD GLUCOSE LEVELS
BLOOD SEPTIC SCREEN

12. Management of DKA OBJECTIVES
✓CORRECTION OF DEHYDRATION
✓CORRECTION OF ACIDOSIS AND KETOSIS
✓ESTABLISHING EUGLYCAEMIA
✓MONITORING DKA COMPLICATIONS
✓IDENTIFY & TREAT TRIGGERS
1.GENERAL MEASURES
2.CORRECTION OF HEMODYNAMIC DISTURBANCE
3.FLUID, ACID BASE & ELECTROLYTES CORRECTION
4.INSULIN THERAPY AND GLUCOSE SUPPLY
SUCCESS DEPENDS ON CLINICAL & LAB MONITORING +
SCHEDULED TREATMENT ADMINISTRATION

13. INITIAL MEASURES ON ADMISSION
OF DKA CASE
•ABC APPROACH:
•A SECURE AIRWAY
•B BREATHING O2 100% WITH FACE MASK WITH RESERVOIR
•C CIRCULATION-VASCULAR ACCESS, CARDIAC MONITORING FOR T WAVES, HR & BP
•RECORD RBG CAPILLARY
•TEST FOR KETONES
•WEIGHT
•DEGREE OF DEHYDRATION
•GCS SENSORIUM AVPU
•COUNSELLING
•LOOK FOR FOCUS OF INFECTION & TREAT

14. Dehydration: Fluid
correction ml / hr
In children 5 –50 Kg BW
Severe DKA 3500 ml / m2 / Day (Max.6L/Day)
Moderate DKA 3000/m2/Day (Max 5L/Day)
Mild DKA Oral
Glycemia >250mg % 2.5%D
<250mg% 5% D
GOALS: 1. Restore circulatory volume
2. Replenish intra -extra vascular H2O &
electrolytes deficits
3. IMPROVE GFR to promote glucose and ketone
clearance from plasma
WEIGHT
IN KGs
No / MILD
ML / HR
MODERATE
ML / HR
SEVERE
ML / HR
5 24 27 31
7 33 38 43
8 38 43 50
10 48 54 62
12 53 60 70
14 60 65 80
16 65 75 85
18 70 80 95

15. FLUID
MANAGEMENT
Based on Kg
BW
No –mild dehydration
Moderate dehydration
Severe dehydration
WEIGHT IN KG NO / MILD ML /
HR
MODERATE ML / HR SEVERE ML / HR
20 75 85 105
22 80 90 110
24 80 95 115
26 85 100 120
28 85 105 125
30 90 110 135
32 90 110 140
34 95 115 145
36 100 120 150
38 100 125 155
40 105 130 160
42 105 135 170
44 110 135 175
46 115 140 180
48 115 145 185
50 120 150 190

16. Potassium correction
❖Generallyinitial dose of 0.5 –0.75 mEq / Kg Infusion over 1 –2 hours
❖Not to exceed 3 mEq / Kg / day
❖Adjust dosage to reach final serum levels of 4.5 mEq / dl
❖Establish adequate renal function and urine output before infusion
❖< 3.3 mEq / L of K+: temporarily hold insulin and give K+ infusion until it is >
3.3 mEq/L
❖K+ > 5.3 mEq / L: do not give K+ & check SR K+ q 2 hyly

17. ACIDOSIS
•Large amounts of CL-rich fluids Administration may result in hyperchloremic
metabolic acidosis
•Masks resolution of ketoacidosis (decreased plasma HCO3 concentration)
•Measure blood ketones (betahydroxy butyric acid
•Replace part of KCL WITH POTASSIUM PHOSPHATE
•BICARBONATE ADMINISTRATION IS ONLY NEEDED WHEN pH < 6.8 in
severe metabolic acidosis with compromised cardiac contractility

18. INSULIN THERAPY
•INTRA MUSCULAR THERAPY: When no facility available for monitoring
•Insulin choice HUMAN ACT-RAPID / SOLUBLE INSULIN / YELLOW LABELLED
•Initial dose: 0.3 U / Kg IM followed by 0.1 U / Kg IM q 1-2 Hrly
•CONTINUOUS INSULIN INFUSION: WHEN FACILITIES FOR MONITORING AVAILABLE :
•START INSULIN THERAPY IN DKA 1HR AFTER STARTING FLUID THERAPY TO AVOID THE RISK
OF CEREBRAL OEDEMA ( EARLY INSULIN ADMINISTRATION RISKS CEREBRAL OEDEMA)
•Initial IV Insulin Infusion is by 0.05 units/ kg/ hr in NS or ½ NS
•Expectant fall of glucose in initial hours is >50mg –70mg / hr
•If glucose fall is not as per expected, hike insulin dose by 0.02U /kg/hr

20. Hypoglycaemia:
Neuroglycopenic
<45 Vs
Adrenergic <55
Rx
Oral glucose or sugar
GLUCAGON 1 mg IM / SC
/OVER 1MIN
S.No ADRENERGIC NEUROGLYCOPENIC
1 HUNGER FAINTING IRRITABILITY
2 PERSPIRATION YAWNING INATTENTION
3 BP RISE WEAKNESS ATAXIA
4 TREMORS TINGLING
5 HEADACHE DIPLOPIA SPEECH
DISTURBANCE
6 PALPITATIONS HYSTERIA
7 ANXIETY DISORIENTATION
8 NERVOUSNESS CONFUSION
9 PALLOR CONVULSIONS / COMA

21. Management of cerebral oedema
•Incidence 0.5 –0.9% with mortality rate of 21 –24%
•GCS < 14
•Occurs during Rx of DKA in 14-15%
•Risk factors: Younger age, newly diagnosed DM, longer duration
of CFs prior to the diagnosis
•Lab diagnosis: Hypocapnia, increased urea, severe acidosis, MRI
BRAIN
•Rx Guidelines: 1. Prompt initiation of therapy upon suspicion 2.
Fluid adjustment to maintain normal BP 3. Hyperosmolarfluid
administration-Mannitol 0.5-1gm/kg I’ve in 10-15 minutes, rptif
needed after 1/2hr and or hypertonic saline 3% 2.5 –5 ml / Kg in
10-15 minutes
•Head raise position 30*
•Hemodynamic support

22. Important formulas
Anion gap: SR Na —(Cl + HCO3)
Corrected SR Na+ : SR Na+1.6{ BG mg% /100 —100}
Effective SR osmolality: 2(measured Na+ mEq/L) + GLU mg% / 18
Total body water deficit: 0.6 x BW in Kg x [ 1 —140/Sr Na ]
Osmolality of 5%D = 252 mOSM/L, 10%D = 555 mOSM/L, NS (0.9%) = 154
10% Cal glu: 1ml = 0.46mEq = 9.3 mg Elemental Ca2+
10ml Cal Glück 10% = 6.8 mOSM ( Cal Glück 1gm)
7.5% NaHCO3 of 10ml = 9.0mEq = 17.9 mOSM = 1790 mOSM/L
4.2% NaHCO3 of 10 ml = 5mEq = 10 mOSM ( 1000mosm/L)