Pediatric Severe DKA - Dr. Magill

Key(toacidosis) Points

Severe DKA definition
- Serum bicarb <5, pH <7.1
- Hyperglycemia
- Dehydration
- Ketosis- ketonemia/ketonuria
- Metabolic acidosis


Fluid resuscitation and insulin infusion
- NS- Initial 10-20 mL/kg over 1-2 hrs
- 3 bag system:
    - Bag 1- insulin (NO INITIAL BOLUS); Start at 0.1 U/kg/hr; Adjust based on q1h BG +/- Q1h BMP
    - Bag 2- NS + 20 KCl + 15 KPhos
    - Bag 3- D5 (or D10) + 1/2NS + 20 KCl + 15 Kphos


Electrolyte abnormalities
- Hypo or hyperkalemia
      - replace in fluids; Max rate 0.5 mEq/kg/hr
- Hypo or pseudohyponatremia
     - replace with fluids and corrects with lowering BG and gap
     - don’t allow > 10-12 mEq/L change in 24 hrs- monitor closely
     - Corrected  Na = measured Na + 0.016 (glucose-100)

- Hypophosphatemia
     - Replace in fluids if < 2mEq/L, monitor Ca2+


- Calcium- membrane stabilizer- takes 15-30 min
     - Calcium Gluconate:
         - Dose: Calcium Gluconate 10%
         - 100 mg/kg slow, Max 5-10mL
         - Less potent, less irritating to veins

     - Calcium Chloride
         - Dose: Calcium Chloride 10%
         - 20-30 mg/kg, Max 5-10mL
         - 3 x more potent than Calcium Gluconate
         - Complication: severe thrombophlebitis

     - Potential Complications of Calcium administration
         - Bradycardia, hypotension and peripheral vasodilation
         - Generally these occur if administered too quickly

---

CErebral Edema

Risk factors
- insulin within first hour
- high fluid volume in first 4 hrs
- severe acidosis
- hypocapnea after adjusting for acidosis
- high BUN
- use of bicarb
- attenuated rise of Na during treatment
- younger age (<5yo)

 Treatment
- IV mannitol 0.5 to 1 g/kg over 20 minutes to be repeated if there is no response in 30 minutes- even if high Osms
- Fluid restriction by one ­third
- Hypertonic saline 3%, 5 to 10 mL/kg over 30 minutes
- Elevate the head of the bed
- Hyperventilation to maintain a PCO2 < 22 mm Hg, although aggressive hyperventilation may be associated with poor outcome
- After treatment of cerebral edema, a CT scan should be performed to rule out other causes of neurological deterioration such as thrombosis or hemorrhage


See PEDEMMorsel on DKA associated Cerebral Edema