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

2. 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

3. Chief Complaints
Dyspnea for 1 day with lethargy

4. 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(-)

5. 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

6. 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

7. 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

8. 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

9. Lab
Finger sugar: 456

10. Image

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

12. 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

13. 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

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

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

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

17. 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

18. Final Diagnosis Type 1 Diabetes Mellitus Diabetic Ketoacidosis
Hypokalemia

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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 = ml
divide over 48 hours = 113 ml/hr
plus maintenance fixed rate = 40 ml/hr
Total = 153 ml/hour

27. 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

28. 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

29. 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

30. 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% g/kg over minutes) or
Hypertonic saline (2.7% or 3% ml/kg over minutes)

31. 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

32. 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): doi: /j.amj

33. 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

34. 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

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

36. 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.

37. 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

38. 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): doi: /j.amj
UpToDate-Cerebral edema in children with diabetic ketoacidosis

39. Thank you for your attention