DKA Paediatrics

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Diagnosis
Management
Algorithm
Insulin therapy
Persisting acidosis
Coma/Cerebral Oedema

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ALL cases of DKA in children must be managed in consultation with senior paediatric staff

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Resuscitation & Fluid management

If shocked reduced level consciousness / coma

• Airway / NG tube
• 100% O₂
• 10ml/kg 0.9% normal saline (may be repeated max x3) until circulation improves

Fluids

• Assess dehydration
• 3% - just detectable
• 5% - dry mucous membranes
• 10% - cap refill > 3 sec, sunken eyes

If < 5% dehydrated

• and tolerating oral fluids give oral fluids

If > 5% dehydrated or clinically acidotic

• Calculate vol to be replaced (deficit + 48 hours maintenance)
  • Deficit (litres) = Body weight (kg) divided by % dehydration
  • 48⁰ maintenance (mls)= [100mls/kg(1^st 10kg) + 50mls/kg(2^nd 10kg)+ 20mls/kg thereafter] x2
• Infuse over 48 hours
• Use 0.9% normal saline until blood glucose < 12mmol/l
• When blood glucose < 12 mmol/l change to 0.45% +dextrose
• Add KCl 20mmol/500ml once urine output confirmed

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Algorithm

• ALL cases of DKA in children must be managed in consultation with senior paediatric staff

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Insulin Therapy

• If < 5% dehydrated and tolerating fluids orally> - start with S/C insulin
• If > 5% dehydrated or clinically acidotic
  • Actrapid infusion (50units actrapid in 50ml 0.9% saline so 0.1 ml = 0.1 unit)
  • Start at 0.1 units / kg / hour (or 0.05 units / kg / hour in younger child)
  • If glucose falls by more than 5mmol / l / hour reduce insulin to 0.05  units / kg / hour
  • If blood glucose continues to fall increase dextrose in IV fluids
  • Do not stop insulin infusion until clinically well and tolerating oral fluids

Ongoing monitoring

• Please move childen to the paediatric ward early, once initial resuscitation intitaied
• Hourly blood glucose, neuro observations and fluid input / output
• Check U&E and Venous blood gases 2 hours post start IV fluids then 4hourly (beware rising Na⁺)
• ECG monitoring as necessary

Coma / Cerebral Oedema

• True coma on admission is rare - consider other causes
• Cerebral ooedema - occasionally present at admission but typically occurs 4-24 hrs after start treatment
  • Gradual deterioration level of consciousness, headache, irritability, signs raised ICP
  • Exclude hyopglycaemia
  • CT Brain
  • Mannitol 0.5 - 1 g/kg  (2.5 - 5 ml / kg 20% mannitol) should be given immediately
  • Restrict fluids by 2/3
  • Discuss with anaesthetic staff re ITU

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Links

ALL cases of DKA in children must be managed in consultation with senior paediatric staff

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Content by "Paediatric Dept CUH Apr 2003", Dr Íomhar O' Sullivan 27/10/2004. Reviewed by Dr John McKiernan29/07/2005, Dr ÍOS 31/05/2007. Next review 31/05/2008.