Case Discussion R1 吳宗祐 R4 呂筱涵 VS 蔡孟哲 2016/11/16

Patient Profile Name: 林X盛 Chart number: 179025xx Age: 5-year-3-month old Gender: Male Date of admission: 2016/11/05~11/11 Informant: Parents and medical records

Chief Complaints Dyspnea for 1 day with lethargy

Present Illness In recent 1 month before admission Easily thirsty Polyuria, urination once per hour, without dysuria, flank pain or fever Decrease of body weight from 18kg to 14kg (-22%) Easy fatigue Poor appetite(-), Easily hungry(-), Sweating(-) Infectious signs(-), Trauma history(-) TOCC(-)

Present Illness 2016/11/05 Tachypnea after waking up with Poor appetite No fever, no cough/sputum, no sore throat No palpitation, no chest pain No cyanosis No nausea/vomit, no diarrhea, no constipation Lethargy NO consciousness change

Present Illness 永康奇美ER Blood sugar 485mg/dl Blood gas: pH 7.084, HCO3- 5.3mmol/L Osmo 313, Ketone 6.4 On CVC and A-line with 0.1ml propofol Normal saline challenge for nearly 250ml Transferred to NCKU

Past History Birth Hx: Medical Hx: Growth and development G2P2, late preterm, C/S due to previous c/s, BBW: 2700+g DOIC(-), PROM(-) Medical Hx: Fever convulsion and UTI when 3 years old Growth and development BH: 110 cm = 15-50th percentile BW: 14.3 kg = ＜3rd percentile BMI: 11.8 kg/㎡ = ＜3rd percentile Development: as normal milestone

PE General appearance: ill-looking T/P/R 35.5/137/22, BP 124/74, SpO2 100% Slow response, drowsy GCS E2V1M5 Heart: Tachycardia, regular, no murmur Chest: Tachypnea(+), breath sound clear, symmetric expansion, wheeze(-), crackle(-) Abdomen: Normal bowel sound, soft and flat, tenderness(-), rebound pain(-) Dry mucosa Normal DTR, pupil and other reflex No urine/stool incontinecne

Lab Finger sugar: 456

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Initial Impression Diabetic Ketoacidosis Plan Admitted to PICU Fluid resuscitation Insulin infusion + Potassium supplement Close monitor dex/gas/electrolites Close monitor neurological signs

Treatment course 2016/11/05-11/07 In PICU 補水 = Maintenance + Loss Maintenance: 14kg = 1200ml/day Loss: 4kg = 4000ml 0~8hr 補2000ml 16-24hr補2000ml Max: 4L*BSA/day = 4 * 0.66 = 2640ml/day = 110ml/hr Insulin continuous run 0.1U/kg/hr Monitor dex/gas/electrolites

Treatment course 2016/11/05-11/07 In PICU Be ware of CNS crisis Consiousness change/Irritation Severe headahce Urine/stool incontinence Vomit Seizure Vital signs change/Pupil size change

Treatment course 2016/11/05-11/07 In PICU

Treatment course 2016/11/05-11/07 In PICU

Treatment course 2016/11/05-11/07 In PICU

Treatment course 2016/11/07-11/11 In 4C RI 4U TIDAC + NPH 4U HS [RI 6U + NPH 4U] QDAC + [RI 3U + NPH 3U] QNAC DM education MBD on 2016/11/11

Final Diagnosis Type 1 Diabetes Mellitus Diabetic Ketoacidosis Hypokalemia

Discussion 1. British Society for Pediatric Endocrinology and Diabetes (BSPED) Guidline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis 2015 2. CASE STUDY -- he Lethargic Diabetic: Cerebral Edema in Pediatric Patients in Diabetic Ketoacidosis

BSPED Guidline for DKA Remember: children can die from DKA Cerebral oedema Unpredictable, occurs more frequently in younger children and newly diagnosed diabetes Mortality around 25% Causes unknown Hypokalaemia Preventable with careful monitoring and management Aspiration pneumonia Use a NG tube in semi-conscious or unconscious children

BSPED Guidline for DKA Diagnose DKA Clinical presentation Acidosis (pH < 7.3 or HCO3 < 18 mmol/L) Ketonaemia pH < 7.1  Severe DKA Clinical presentation Clinical dehydration Nausea and/or vomiting Drowsiness Acidotic respiration Abdominal pain

BSPED Guidline for DKA Emergent management A-B-C Initial fluid bolus Only if shocked, give 10ml/kg N/S as a bolus. Do not give more than one bolus without discussion with the responsible senior paediatrician

BSPED Guidline for DKA Full Clinical Assessment Conscious Level Looking particularly for evidence of Cerebral edema -- headache, irritability, slowing pulse, rising blood pressure, reducing conscious level *Papilloedema is a late sign. Infection Ileus Weigh the patient

BSPED Guidline for DKA Fluid ((All fluids given should be documented)) Requirement = Deficit + Maintenance Assume 5% of fluid deficit in mild-moderate DKA Assume 10% of fluid deficit in severe DKA Maintenance: BW<10kg  2ml/kg/hr; 10<BW<40kg  1ml/kg/hr; BW>40kg  fix 40ml/hr Note: large fluid volumes are associated with an increased risk of cerebral edema

BSPED Guidline for DKA Fluid Resuscitation fluid – If > 20 ml/kg N/S has been given  minus additional volumes. Fluid calculation 5% or 10% deficit, divide over 48 hrs and add to the maintenance Type of fluid 0.9% N/S with 20mmol KCl in 500 ml (40 mmol/L) until blood glucose < 252 mg/dl

BSPED Guidline for DKA 20 kg 6y/o boy, pH of 7.15 deficit 5 % x 20 kg = 1L = 1000ml  divide over 48 hours = 21 ml/hr plus maintenance 1ml/kg/hr = 20 ml/hr Total = 41 ml/hour 60kg 16y/o girl, pH 6.9, given 30ml/kg N/S deficit 10 % x 60 kg = 6000 mls minus 10ml/kg resuscitation fluid = - 600 ml divide over 48 hours = 113 ml/hr plus maintenance fixed rate = 40 ml/hr Total = 153 ml/hour

BSPED Guidline for DKA Potassium Insulin All fluids should contain 40 mmol/L KCl, unless there is evidence of renal failure Insulin There is some evidence that cerebral edema is more likely if insulin is started early. Do not give bolus doses of IV insulin Start insulin infusion 1-2 hours after beginning of IV fluid therapy 0.05 ~ 0.1 units/kg/hour

BSPED Guidline for DKA Bicarbonate Do not give IV NaHCO3 UpToDate: Unless severe acidosis (pH <6.90), particularly those with impairment of cardiac contractility or lifethreatening hyperkalemia

BSPED Guidline for DKA Monitoring Strict fluid balance Finger Sugar Q1H/Blood Ketone Q2H Q1H check vital signs/Conscious level Q30min if <2y/o, or pH<7.1 ECG monitor, be ware of signs of HypoK, including ST-depression, prominent U-waves Check body weight Q2D

BSPED Guidline for DKA Cerebral Edema Early manifestations: Headache, agitation or irritability, Unexpected fall in HR, increased BP If cerebral oedema is suspected, treat immediately with Mannitol (20% 0.5-1 g/kg over 10-15 minutes) or Hypertonic saline (2.7% or 3% 2.5-5 ml/kg over 10-15 minutes)

BSPED Guidline for DKA Cerebral Edema If a child develops any of these signs – Deterioration in level of consciousness Abnormalities of breathing pattern, for example respiratory pauses Oculomotor palsies Abnormal posturing Pupillary inequality or dilatation. Treat as cerebral edema Decrease the fluid to ½ maintenance rates

Case Study The Lethargic Diabetic: Cerebral Edema in Pediatric Patients in Diabetic Ketoacidosis Samantha W. Gee, MD Air Med J. 2015 Mar-Apr;34(2):109-12. doi: 10.1016/j.amj.2014.10.009.

Case 4 y/o male with a hx of Type 1 DM Difficulty breathing and decrease responsiveness Nausea/vomit for 1-2 days, Lethargic state Lab: severe DKA, pH 6.94, Glu 620mg/dl, HCO3 6mmol/L, BUN 15mg/dL, Cre 0.99mg/dL Treatment: 40ml/kg fluid resuscitation + Insulin 0.1 U/kg/hr Transport to tertiary care hospital via helicopter No bolus insulin, No sodium bicarbonate Within 30mins transport team arrived: Vital signs: HR 151, RR 36 Peripherally cool with capillary refill 2 seconds Accessory muscle use on inspiration, SpO2 100% on room air Lethargic; pupils 3 mm, equal and reactive, GCS 10 (E2/V4/M4) Blood glucoses decreased from 620 mg/dL to 453 mg/dL  Taper down Insulin drip to 0.05U/kg/hr Fluid: 0.45 normal saline with 20 mEq/L KCl at a maintenance rate

Case During transportation On arrival Sleepy, GCS 10~15 Intervals of “awake and crying, able to be consoled” to “sleeping, arouses easily to touch.” Vital signs: HR 144~183, RR 36~44, BP 147~163/66~78 On arrival GCS 11 “responsive only to pain, not interactive, not talking” and “somnolent, Kussmaul breathing, responds to painful stimuli and intermittently cries but not awake or talking.” Vital signs HR 138, RR 44, BP 157/83

Case Head CT Cerebral edema!! 0.5 g/kg IV mannitol Admitted to PICU

Case PICU Neurological status deteriorated Hyperosmolar fluid therapy A bolus dose of 5 mL/kg IV 3% NaCl IV fluid slow down at 1.5 times maintenance. Serum Na maintained > 140 mmol/L. During the first 12 hours, not to decrease his blood glucose more than 50 mg/dL/h The patient improved. At the 24-hour mark of his PICU stay  GCS 15 No neurologic deficits were appreciated upon discharge to home.

Take home message Children can die from DKA Cerebral oedema careful evaluation and monitoring for signs and symptoms Hypokalaemia Aspiration pneumonia DKA is a state of hyperosmolar dehydration Volume expansion should be achieved gradually and with isotonic fluids Monitor glucose, ketone, acid-base and electrolites frequently NOT treating with bicarbonate Unless severe acidosis (pH <6.90), particularly those with impairment of cardiac contractility or lifethreatening hyperkalemia

Reference BSPED Guidline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis 2015 The Lethargic Diabetic: Cerebral Edema in Pediatric Patients in Diabetic Ketoacidosis Samantha W. Gee, MD Air Med J. 2015 Mar-Apr;34(2):109-12. doi: 10.1016/j.amj.2014.10.009. UpToDate-Cerebral edema in children with diabetic ketoacidosis

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