Pediatric endocrine fellow DIABETIC KETOACIDOSIS Presented by: Dr Fawzia Alyafei Pediatric endocrine fellow Hamad medical Hospital 22/12/ 2015

Agenda Case 1 Case 2 Case 3 DKA order set

Case 1

Case 1 Ahmed 12 years old boy previously healthy presented with Vomiting (recurrent) for 12 hours Abdominal pain and fatigue sever dehydrated WT = 45 kg HR= 170 , BP= 80/50 mmHg ,CRT =3seconds Labs : Glucose 550 mg/dl, Na= 131 , K = 4.5 , HCO3 = 10 , PH = 7.15 B hydroxybutrate= 4

WT = 45 kg HR= 170 , BP= 80/50 mmHg ,CRT =3seconds Labs : Glucose 550 mg/dl, Na= 132 , K = 4.5 , HCO3 = 10, PH = 7.15 B hydroxybutrate= 4 1- What is the diagnosis ? and how many types it has? 2-How many parts in the treatment ? 3-How to treat it ? Including (fluid maintenance and deficit , amount of fluids in the first hr and amount of fluids ml/ kg/ hr later )

What is the definition of DKA? What is the diagnosis? Newly diagnosed DM with DKA What is the definition of DKA? Clinically (Rapid deep breathing Abdominal pain Vomiting Disturbed level of consciousness ) Biochemically 1-Hyperglycemia : (blood glucose >11 mmol/L [≈200 mg/dL]) 2-Acidosis : Venous pH <7.3 and bicarbonate <15 mmol/L 3-Ketonemia and ketonuria. ISPAD 2014

-Mild PH<7.3 & HCO3<15 -Moderate PH<7.2 & HCO3<10 -Sever  PH<7.1 & HCO3<5

Pathophysiology of DKA! How many parts in the treatment ? Pathophysiology of DKA!

Pathophysiology of DKA ISPAD 2014

How many parts in the treatment ?

Life threatening condition How to treat it ? Life threatening condition 1- Resuscitation and fluids A:Airway B:Breathing C:Circulation  2 large IV lines ( Insulin ,C-peptide , HBA1C, Anti TPO, Thyroid function test, Celiac screen, GAD antibody, Vitamin D) Fluid resuscitation (10-20ml/kg) 900ml over 1 hr ? Times History

1- Resuscitation and fluids A-Fluid maintenance 2L B-Fluid deficit A- 4.5L B-6.75L C-2.25L

1- Resuscitation and fluids A-Fluid maintenance 2L B-Fluid deficit A- 4.5L B-6.75L C-2.25L C-Total fluid (ml/hr) A- 177ml/hr B- 135ml/hr C- 158ml/hr Sever dehydration 10%

1- Resuscitation and fluids A-Fluid maintenance 2L B-Fluid deficit A- 4.5L B-6.75L C-2.25L C-Total fluid (ml/hr) A- 177ml/hr B- 135ml/hr C- 158ml/hr D-Do not add urine output to the replacement volume ≤ 4 liter/m2/day Correction over 48hr

2- Types of fluids(electrolytes) Sodium A-0.9n Nacl in the first 6hr B-0.45 Nacl in the first 6hr C- Ringer lactate D- According to the Na level

2- Types of fluids(electrolytes) Sodium A-0.9n Nacl in the first 6hr B-0.45 Nacl in the first 6hr C- Ringer lactate D- According to the Na level

2- Types of fluids(electrolytes) Sodium A-0.9n Nacl in the first 6hr D- According to the Na level If corrected Na<1500.9 saline corrected Na>1500.45 saline

Is it a real hyponatremia? Example Ahmed received 0.9 Nacl for 6hr , repeated Na was 128 mmol/l and his glucose was 550mg/dl Is it a real hyponatremia? A-128 B-131 C-135

Is it a real hyponatremia? Example Ahmed received 0.9 Nacl for 6hr , repeated Na was 128 mmol/l and his glucose was 550mg/dl Is it a real hyponatremia? A-128 B-131 C-135 Corrected Na = serum Na + 1.6 mmole/L (for every 100 mg/dl serum Glucose above 100 mg/dl)

2- Types of fluids(electrolytes) Potassium (when to start?) A-Immediately B-After 4 hrs C-After Checking potassium lab level D-After passing urine

2- Types of fluids(electrolytes) Potassium (when to start?) A-Immediately B-After 4 hrs C-After Checking potassium lab level D-After passing urine If not available,can use ECG (T waves)

What is the amount of potassium ? WT = 45 kg HR= 170 , BP= 80/50 mmHg ,CRT =3seconds Labs : Glucose 550 mg/dl, Na= 132 , K = 4.5 , HCO3 = 10, PH = 7.15 B hydroxybutrate= 4 What is the amount of potassium ? A- No K B-2 mmol/dl per 100 ml C-4 mmol/dl per 100 ml D- 6 mmol/dl per 100 ml

What is the amount of potassium ? WT = 45 kg HR= 170 , BP= 80/50 mmHg ,CRT =3seconds Labs : Glucose 550 mg/dl, Na= 132 , K = 4.5 , HCO3 = 10, PH = 7.15 B hydroxybutrate= 4 What is the amount of potassium ? A- No K B-2 mmol/dl per 100 ml C-4 mmol/dl per 100 ml D- 6 mmol/dl per 100 ml What is the form of potassium ? A-KCL only B-2mmol/l KCL and 2mmol/L KPO3 (50%) C-3mmol/l KCL and 1mmol/l KPO3 (70/30) % D-2mmol/L K acetate and 2mmol/L KPO3 (50%) E-KPO3 only

What is the amount of potassium ? WT = 45 kg HR= 170 , BP= 80/50 mmHg ,CRT =3seconds Labs : Glucose 550 mg/dl, Na= 132 , K = 4.5 , HCO3 = 10, PH = 7.15 B hydroxybutrate= 4 What is the amount of potassium ? A- No K B-2 mmol/dl per 100 ml C-4 mmol/dl per 100 ml D- 6 mmol/dl per 100 ml What is the form of potassium ? A-KCL only. B-2mmol/l KCL and 2mmol/L KPO3 (50%) C-3mmol/l KCL and 1mmol/l KPO3 (70 /30) % D-2mmol/L K acetate and 2mmol/L KPO3 (50%) E-KPO3 only.

2- Types of fluids(electrolytes) Potassium -After Checking potassium lab level Or -After passing urine -If Potassium > 5.5mmol/dl  No K 4-6 mmol/dl 4 mmol/l < 4 mmol/dl  6 mmol/l

What is the best type of fluid for him ? Ahmed maintained on fluid and repeated RBS 230 mg/dl What is the best type of fluid for him ? A- 0.9Nacl B- 0.9 Nacl D5% C- 0.45 Nacl D5% D- 0.9 Nacl D10% E-0.45 Nacl D10%

What is the best type of fluid for him ? Ahmed maintained on fluid and repeated RBS 230 mg/dl What is the best type of fluid for him ? A- 0.9Nacl B- 0.9 Nacl D5% C- 0.45 Nacl D5% D- 0.9 Nacl D10% E-0.45 Nacl D10%

2- Types of fluids(electrolytes) Dextrose 1- If Blood glucose <250 mg/dl OR blood glucose fall >5mmol/L/hr Change IV to D5 to the fluids . 2- If Blood glucose <150 mg/dl change to D10 . 3-alwayes change the saline type to 0.45 Nacl when you add dextrose .

What is the dose of insulin ? A- 45 units /hr B- 4.5 units/hr C-2.25 units/hr D-25 units/hr E-3.5 units /hr

What is the dose of insulin ? A- 45 units /hr B- 4.5 units/hr C-2.25 units/hr D-25 units/hr E-3.5 units /hr

What is the type of insulin ? A- Lantus B-Novomix C-Actrapid D-Novorapid E-Apidra

What is the type of insulin ? A- Lantus B-Novomix C-Actrapid D-Novorapid E-Apidra

When to start the insulin ? A- Immediately B- After 1 hour C- After 2- 4 hours

When to start the insulin ? A- Immediately B- After 1 hour C- After 2- 4 hours

3- Insulin 1-IV insulin infusion 0.1 units/kg/hr. 2-Don’t give insulin bolus . 3- Actrapid insulin . 4-To be started 1hr from fluids .

1-Continues Cardio-respiratory monitoring hourly 4-Montrining How to monitor DKA ? 1-Continues Cardio-respiratory monitoring hourly 2-Intake and output chart 3-RBS q 1 hr 4-Electrolyte and VBG q 2 hr

4-Montrining Admit to PICU or Floor or daycare? 1-All newly diagnosed DM with DKA MUST be admitted to the floor or PICU . 2-newly diagnosed DM with DKA might be seen in daycare if no beds and finished 24hr observation .

4-Montrining Admit to PICU or Floor ? 1- Children with severe DKA (PH<7.1 &/or HCO3 < 10) 2- Cardiovascular Compromise 3- Depressed level of consciousness 4- Sign of cerebral edema: 5- <5 years of age 6-Seizure 7- Electrolytes imbalance

4-Montrining Admit to PICU or Floor ? 1- Children with severe DKA (PH<7.1 &/or HCO3 < 10) 2- Cardiovascular Compromise 3- Depressed level of consciousness 4- Sign of cerebral edema: 5- <5 years of age 6-Seizure 7- Electrolytes imbalance

Case 2

Case 2 Abdulla 7 years old boy K/C type 1 DM presented with Vomiting of 1 day Abdominal pain and fatigue moderate dehydrated WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4

WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 5.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 1- What is the diagnosis ? What type is it ? 2-How to treat it ? All parts Including (fluid maintenance and deficit and amount of fluids ml/ kg/ hr later ) 3-What are the possible triggers for his diagnosis? 4-If Ahmed was not improving with the treatment (persistence acidosis and hyperglycemia ) what are the possible causes? 5-when to stop the treatment ?

1- What is the diagnosis ? DKA What type is it ? A- mild B-Moderate C- sever

1- What is the diagnosis ? DKA What type is it ? A- mild (PH>7.2, HCO3>10) B-Moderate C- sever

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 1- Resuscitation and fluids A:Airway B:Breathing C:Circulation  2 large IV lines (HBA1C in the last 3 months ) Fluid resuscitation

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 5.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 1- Resuscitation and fluids A-Fluid maintenance 1600 ml B-Fluid deficit 2500 ml (sever dehydration 10%) C-Total fluid (ml/hr) 118ml/hr Remember not to exceed 4L/m2/day

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 2-Electrolytes Type of fluid ? 0.9Nacl 118ml/hr +3meq KCL and 3meq KPO4

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 3- Insulin Type of insulin and dose ? IV Actrapid 2.5U/hr

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 550 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 If blood glucose dropped from 550 to 380 mg/dl in one hour what can you do ? A-Add D5 to fluid for the next hr B-Decrease fluid rate for the next hr C-Decrease insulin for the next hr D-Stop insulin for 1 h

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 550 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 If blood glucose dropped from 550 to 380 mg/dl in one hour what can you do ? A-Add D5 to fluid for the next hr B-Decrease fluid rate for the next hr C-Decrease insulin for the next hr D-Stop insulin for 1 h

Types of fluids(electrolytes) Dextrose 1- If Blood glucose <250 mg/dl OR blood glucose fall >100mg/dl/hr Change IV to D5 to the fluids . 2- If Blood glucose <150 mg/dl change to D10 . 3-alwayes change the saline type to 0.45 Nacl when you add dextrose .

2-How to treat it ? All parts WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : Glucose 350 mg/dl, Na= 135 , K = 3.5 , HCO3 = 12 , PH = 7.25 B hydroxybutrate= 4 4- Monitoring 1-Continues Cardio-respiratory monitoring hourly 2-Intake and output chart 3-RBS q 1 hr 4-Electrolyte and VBG q 2 hr

3-What are the possible triggers for DKA? 1- Missing the insulin dose (Basal) 2-expired insulin or pump failure 3-Infection 4-lipohypertropthy

4-If Ahmed was not improving after 4 hr from the treatment (persistence acidosis and hyperglycemia ) what are the possible causes? 1- Calculation (Fluids and insulin) 2-IV lines 3-expaired insulin 4-Infection

NO need for admission Unless 1- Sever DKA Admit to PICU or Floor ? 2-Recurrent DKA

PH >7.3 HCO3 >15 H 5-when to stop the DKA protocol ? WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : RBS 300 mg/dl, Na= 138 , K = 3.5 , HCO3 = 18 , PH = 7.35 B hydroxybutrate= 0.5 PH >7.3 HCO3 >15 H

How to stop the DKA protocol WT = 25 kg HR= 110 , BP= 100/70 mmHg ,CRT <2 seconds Labs : RBS 300 mg/dl, Na= 138 , K = 3.5 , HCO3 = 18 , PH = 7.35 B hydroxybutrate= 0.5 1- Check RBS and allow oral intake if tolerated 2- Start : sliding scale insulin  Subcantouse (SC) actrapid (3.75Units) 3-If known case of DM shift them back to their insulin regimen (basal and prandial ) 4-D/C IV insulin 30 min after SC insulin 5-D/C IVF when patient taking orally without vomiting 6-RBS premeal and Bed time

Never stop IV insulin without giving it SC first How to stop the DKA protocol 1- Check RBS and allow oral intake if tolerated 2- Start : sliding scale insulin  Subcantouse (SC) actrapid Blood sugar (mg/dl) Insulin dosage (units) 100- 150  0 .05 UNITS /Kg  If this value before meals 151- 250  0.1 UNITS /Kg 251 – 400 0.15 UNITS /Kg >400 0.2 UNITS /Kg 3-If known case of DM shift them back to their insulin regimen 4-D/C IV insulin 30 min after SC insulin 5-D/C IVF when patient taking orally without vomiting 6-RBS premeal and Bed time IF RBS was 90mg/dl Never stop IV insulin without giving it SC first

Case 3

Case 3 Ali 10 years old boy previously healthy presented with Vomiting (recurrent) for 1day Abdominal pain and fatigue mild dehydrated Diagnosed as G/E given ORS and sent home with instruction of possibility to have vomiting in the coming few days and not to worry , No labs were done . Patient came 2 days later ill looking severely dehydrated with rapid breathing WT = 35 kg HR= 190 , BP= 60/40 mmHg ,CRT =4seconds Labs : Glucose 600 mg/dl, Na= 127 , K = 4 , HCO3 = 3 , PH = 6.9 B hydroxybutrate=5

2-How to treat him using orderset sheet ? WT = 35 kg HR= 190 , BP= 60/40 mmHg , CRT =4seconds Labs : Glucose 600 mg/dl, Na= 127 , K = 4 , HCO3 = 3 , PH = 6.9 B hydroxybutrate=5 1-What is the type of DKA? 2-How to treat him using orderset sheet ? 3- 12 hr from treatment Ali started to complain from headache and drowsiness what are the possible causes? And how to treat it? 4-Should the patient be admitted and where ?

350 0.9 139 3.5

35 93

1-Younger age < 5 years 2- New onset diabetes 3- Severe DKA. Factors that increases risk of cerebral edema 1-Younger age < 5 years 2- New onset diabetes 3- Severe DKA. 4- Hypocapnia at presentation after adjusting of acidosis 5- Impaired renal function. 6- Bicarbonate treatment for correction of acidosis . 7- Greater volumes of fluid given in the first 4 h . 8- Administration of insulin in the first hour of fluid treatment

Thank you Question ?