STEP BY STEP MANAGEMENT OF DKA See details in the DKA protocol guidelines Dr. D. Alvarez Up-dated 5-10

(DKA) General DKA is a life-threatening, preventable complication of diabetes Characteristics Inadequate insulin action, Hyperglycemia >BS > 200 > HYPEROSMOTIC STATE (Polyuria) Dehydration > pre-renal azothemia Electrolyte loss > K, Na, Ph, Mg and Glucos Metabolic acidosis, and ketosis.

INITIAL PROCES Call from ED requesting bed Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED as activity in the unit warrants. Form to be taken to the ED to start documentation: “30 sec assessment”- Laboratory flow sheet – DKA Flow sheet – System by System flow sheet Information needed: Base line patient’s chronic condition control status: last HbA1c, last diabetic clinic visit with assessment, current dose of insulin, time last dose. HPI, duration of symptoms. Triggering factors, Interventions.

ED Course 3. Note: time of arrival to the ED. ED assessment (fill up “30 sec assessment” labs (start laboratory flow sheets) and therapy Get Ht, Wt and SA ( m2) to start doing calculations. 4. Communicate with PICU Attending and inform on patient’s condition to Nurses and Supervisor (if applicable)

Physiological Problems that will need to be address. Address Severity of: DKA /Acidemia: CO2 Ph (V) Clinical Normal 20-28 7.35 – 7.45 Normal Base line Mild 16-20 7.25 – 7.35 Oriented, alert but Fatigued Moderate 10-15 7.15 < 7.25 Kussmaul Resp. Oriented, Sleepy but arousable. Severe <10 < 7.15 Kussmaul Or Depressed Resp./Sleep/ alter Mental> Coma.

Physiological Problems that will need to be address. Address Severity of: 2. Hyperglycemia / Heperosmolarity Can request to be measure directly in the lab OR Calculate it by formula Osm = 2 x Na +glucose/18 + BUN /2.8 Normal Osmolarity ~ 300

Address Severity of: 3. Dehydration: Mild Moderate Severe Infant 5-7 % 10-15% 15-20 % Younger Child 3-5 % 7-10% 15% Older Child -Adolesc 3 % 7 % 10%

4. Electrolyte Imbalance: Address Severity of: 4. Electrolyte Imbalance: Na: correct serum sodium level as per formula Add 1.6 for each 100 mg/dl of glucose over 100 Example: if Na 130 and BS of 800 Corrected Na will be 1.6 x 700 = 11.2 130 + 11.2 =141 (this is the true Na, still the total body sodium is low) K: even though the serum K may be initially high, the total body sodium is always low. Ph and Calcium abnormalities as well

MANAGEMENT

Fluid Replacement Calculations Start filling up DKA flow sheet Check how much and what kind of fluids patient received in ED. (usually patient should had received NS, 20 to 40 cc/kg boluses) Check if patient passed urine and how much and calculated Fluid Balance Example: if patient received 1 Liter of NS and passed 1 liter of urine because hyperosmolarity; the balance is ZERO.

Fluid Replacement Calculations (CONTINUES) 3. Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2) Wt base: 100 ml/kg for the first 10 kg 50 ml/kg for the next 10 kg 20 ml/kg for the rest…. kg. Per SA (m2) 1500 mL/M2 4. Calculate deficit for ideal (pre-illness) wt. Example: Pt. is 22.2 kg. Maintenance is 1540 mL

Fluid Replacement Calculations (CONTINUES) 4. Calculate deficit per ideal (pre-illness wt) Example: Pt. current (dehydrated) wt is 20 kg Pt. is assess to be 10% dehydrated. Ideal wt is: 22.2 kg (20 kg is 90% >>> 100 % =100 x 20 / 90) Deficit will be 22.2 – 20 = 2.2 Liters

Fluid Replacement Calculations (CONTINUES) 4. To calculate IV rate: ml/hr Add Maintenance + ½ of deficit (*) 1540 + 1.1= 2640 mL in 24 hrs - IV rate of 2640/24 hr = 110 cc/hr. (*) correction should be given in 48 hrs. 5. IV solution selection: use standard solution pre-mixed by pharmacy: There are 3 standard solutions. To select them go to> IV solution (16) > then select “IV solution (peds)” (7) >> from Solution for DKA - 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter - D5% 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter - D 10% 0.45 NS with 20 mEq KCl and 15 mM of KPh / Liter

Ordering Standards DKA Solutions In the Order entry >Select # 23 (IV Solutions) Pediatric Common IV Solutions-Order options > Select # 7 (IV sol (Ped)…. If Patient has severe hyperosmolarity (Osm >350), hyponatremia and hyperkalemia (K > 5.8) keep running Isotonic solution till repeat BMP and document that K is decreasing before ordering K containing solutions If needed can piggi-bag (PB) Examples - NS at 100 mL/h PB with ½ NS 80 ml/hr for a total rate of 180 mL/hr - NS at 100 ml/hr PB with D5 ½ NS 80 ml/hr for a total rate of 180 mL/hr IV Maintenance Solution for DKA Management (Potassium, Phosphate, Potassium Chloride) > Select 5, 6, 7, Or 8 15 mmol kPO4 / 20 mEq KCl in NaCl 0.45 % 1000 mL 15 mmol kPO4 / 20 mEq KCl in D5% NaCl 0.45% 1000 mL 15 mmol kPO4 / 20 mEq KCl in D10% NaCl 0.45% 1000 mL 15 mmol kPO4 / 20 mEq KCl in D5% NaCl 0.9% 1000 mL

Insulin drip Dose: 0.05 to 0.1 Units /kg/hr. Choice will depend on: the severity of the acidosis. If severe, start with 0.1 U/kg/hr (may need to go higher if patient not responding) The patient’s sensitivity to Insulin, according to age and individual response. Solution Concentration: select standard solutions given on “Misys” RUN IT IN A SEPARATE IV LINE.

Insulin drip order Using standard Solution Concentration Order entry: Select # 22 IV Drip Pediatric IV Drip Order Options Select # 6 “Insulin, Human, Regular” Pediatric Dose: select according to guidelines, computer will calculate IV rate according to entered Wt.

Insulin drip order (cont.) Using standard Solution Concentration BE SURE THAT THE CORRECT WT WAS ENTER BEFORE ORDER IS WRITTEN 1.- 25 Units/100 mL NS @ 0.05 Unit/kg/hr 2.- 25 Units/100 mL NS @ 0.075 Unit/kg/hr 3.- 25 Units/100 mL NS @ 0.1 Unit/kg/hr 4.- 25 Units/100 mL NS @ ____ Unit/kg/hr WRITE INDICATIONS as well (DKA) RUN IT IN A SEPARATE IV LINE.

FOLLOW - UP Cardio-respiratory monitoring and Neuro checks Neuro checks: observe for changes of metal status as signs of dehydration and or complications of DKA: Cerebral edema, strokes Respiratory: Observe for changes/ type of respiration as sign of acidosis (Kussmaul respirations) and /or respiratory depression 2nd to CNS depression as an imminent CNS complication. CV: Observe for signs of dehydration and / or electrolyte abnormalities, I.e. Hyper /hypokalemia.

FOLLOW - UP 2. Fluid Balance The goals of fluid therapy are: Initial fluid resuscitation is aim to replenish intravascular volume to reverse lactic acidosis. Slow rehydration (48 hr) and slow decrease in osmolarity to prevent risk of cerebral edema. Divide the 24 Fluid deficit by 3 to anticipate /estimated the positive 8 hour balance to achieve Example: Calculated fluid correction deficit in 24 hrs is 1500 mL. 1500/3 = 500 mL (Need to have a Positive balance of ~ 500 every 8hrs) Daily Wt will be the best objective way to assess rehydration

FOLLOW - UP 3. Acid-Base-Balance VBG and electrolytes including Ca and Ph every 2-3 hours until a steady improving trend, then it can be done Q 4-6 hours till all normal. 4. FS Q1H as long patient is on insulin drip Aim to have a slow decrease of BS /Osmolarity, may need to add glucose containing solution and /or use NS for a longer period of time at the beginning of rehydration. If started with high BS & Osmolarity, change to D5% /SS when the FS falls < 250 and adjust IV solutions to keep FS between 100 -150 At the beginning and until the acidosis is corrected, control BS with IV solutions with or without Dext. using the “2 bag system”

“2 bag solutions” Acidosis improving Acidosis Resolved Patient No changes in Insulin drip, except for temporarily hold if low FS (< 80) until corrected with Glucose solutions. Adjust IV solution rates to keep FS Between ~150 (increase Dextrose Sol if < 100 or decrease if close to 200) Acidosis Resolved Patient is ready to have the insulin drip switch to SC (dose to be given by Endocrinologist) and start Diabetic Diet. If FS is low can decrease Insulin drip instead of increase Glucose in the IV solution. After the first dose of SC given and Pt. Ate. D/c insulin drip after 1 hr. D5% Or D10% 0.45 NS with K…(Same) 0.45 Or D5% NS with K…(same) Piggy-bag Adjust rate. Patient Calculated rate: Main + deficit / mL/hr

Switching Insulin from drip to SC Get SC dose of insulin from Endocrinologist Order Diet as per Endo recommendations, usually: If < 5 yo is 3 meals and 3 snack If > 5 yo 3 meals and 2 snacks Order initial Insulin dose as per endocrinologist. (see separate slide guidelines on how to write order) NPH dose is usually started in AM before breakfast. Lantus is usually given PM Humalog coverage for Glucose and/or carbohydrate caloric count. D/C insulin drip 1 hours after SC dose given D/C glucose in IV fluids as soon as patient starts eating meal Decrease IV fluid rate to calculated Replacement Rate only. Change schedule of FS to 7 times /day as per diabetic protocol. (see guideline orders)

Ordering insulin in relation to Carbohydrate caloric count 7/08 Order entry write “Humalog” Select (1) ____Units SC Now Select Expand (on the low right corner Select (5) Route ___ Choose #78... > Select Expand (button right corner button) Select # 7( --- x perday), and 28 (Schedule at) Write 5 x perdaySchedule at (enter) Frequency.5xdaySchedule Time Options * (1) (2) (3) (4) (5)

(1) breakfast (chose option D-During), Ordering insulin in relation to Carbohydrate caloric count > 7/08 (Continue) * For each # selected click “expand” as follow: (1) breakfast (chose option D-During), (2) lunch (chose option D-During), (3) select 1- time & write 1500 for afternoon snack; (4) Super (chose option D-During), (5) select 1 - time & write 2100. for eve snack 10. Under instructions Select # 27 Other ___ write the amount of insulin as per example: Example: 15 minutes before meal and snack check BS and administer (x) Units of Humalog for each (x ) grams of carbohydrate and (x ) Unit for each ( x ) mg/dl glucose level above the patient target (X) mg/dl. NOTIFY MD TO WRITE ORDER FOR THE AMOUNT OF INSULINE CALCULATED.

Ordering SC insulin coverage using Sliding Scale 1 to 7 is the same as per carbohydrate count. 8. Write 3 x (if No coverege for snacks) Or 5 if coverage coverage for snacks perdaySchedule at (enter) 9. Frequency.3 xdaySchedule Time Options * (1) (2) (3) For each # selected click “expand” as follow: (1) breakfast (chose option D-During), (2) lunch (chose option D-During), ( ) select 1- time & write 1500 for afternoon snack; (3) Super (chose option D-During), (5) select 1 - time & write 2100. for eve snack 10. Under instructions Select # 26 Other ___ write the amount of insulin as per example: Example: Check BS 15 min before meals and give the following coverage: Breakfast: Give (X) Units if FS is < 100, Give (X) Units if FS is >101< 200; Give (X) Units if FS is >201 and < 300; Give (X) Units if FS is > 300. Lunch: Give ( X ) Units if FS is < 100, Give (X) Units if FS is >101< 300; Give (X) Units if FS is > 300. Dinner: Give ( X ) Units if FS is < 100, Give (X) Units if FS is >101< 300; Give (X) Units if FS is > 201 but < 300; Give (X) Units if FS is > 300;

Dextrostics (FS) monitoring when pt. in on SC insulin Dextrostics (FS) monitoring when pt. in on SC insulin. 7 (times per day) Order entry … “dextrosticks “ (Fingersticks Glucose by Nursing) 2. Expand… 3. Choose # 7 ( _ X per day) 4. Write 7 (times per day) 5. In instructions field please Write : As per diabetic protocol, using Glucometer

Complication of DKA BEWARE

CNS Cerebral Edema > high mortality Multifactor cause. Typically develops within the first 24 hrs of treatment of DKA Symptoms and signs include headache, confusion, slurred speech, bradycardia, hypertension, and signs of increased intracranial pressure: sluggish pupils, decrease mental status Things to avoid Rapid rehydration (aim rehydration in 48 hrs): Initial NS bolus should to given to improve hemodynamical status ONLY i.e, improve perfusion, treat hypotension and keep good urine output Tachycardia takes time to improve (it has many factors, including high adrenergic stress release) Avoid Hypotonic Fluids Rapid changes in osmolarity, (aim / goal to decrease Blood sugar no more than100 mg/dl/hr)- May need to add dextrose solutions early to prevent it

CNS Complications Cerebral Edema > high mortality Treatment is aim to decrease intracranial pressure. Prompt administration IV Mannitol (0.25–1 g/kg) is the best option Tracheal intubation to mechanically hyperventilate and surgical decompression with ventriculostomy are less successful at preventing mortality or severe disability. Intracranial imaging to exclude other pathologies, such as cerebral infarction or thrombosis, should be obtained but not at the expense of timely therapeutic interventions. 2. Other less common complications of DKA include thrombosis, a particular concern in children who require a central venous catheter for access

Electrolytes Hyperkalemia/hypokalemia: high risk for arrythmias Continuous cardiac monitoring EKG Hypophosphatemia Hypocalcemia, special if using Phosphate supplement.

Other less common complications of DKA Pulmonary edema; Renal failure; Pancreatitis; Rhabdomyolysis; and Infection, such as aspiration pneumonia, sepsis, and mucormycosis

Case Exercise- Example on Initial Management Pt. 15 yo HF, know IDDM since 10 yo, poorly controlled (HbA1C 15), admitted in severe DKA Lethargic VS: T 98 F, HR 150, RR 30, BP 130/75 O2Sat 96 % Wt. 50 kg Poor perfusion Labs: VBG: Ph 7.0 /CO2 7 / Bic 8, BE – 20 BMP: Na133/K5.2/Cl98/5/AG 15/BS 800 / BUN 20/ Cr 1.2, Ca 9