3a Emergency Care DKA (UK) FINAL(2)

7/28/2019 3a Emergency Care DKA (UK) FINAL(2)

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Presentation title

Emergency Care

Part 1: Managing Diabetic Ketoacidosis(DKA)


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Slide No 2Slide no 2

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Managing DKA

Surgery in children with diabetes

Treating and preventing hypoglycaemia

Programme


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Slide No 3

Diabetic Ketoacidosis

Occurs when there is insufficient insulin action

Commonly seen at diagnosis

Is a life-threatening event

Child should be transferred as soon as possible to thebest available site of care with diabetes experienceInitiate care at diagnosis

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Slide No 4

Type 1 Diabetes

Increased urine

Dehydration Thirst


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Slide No 5

DKA

Weight loss

Ketones

Nausea

Vomiting

Abdominal pain

Altered level ofconsciousness

Shock

Dehydration

Liver

Muscle

Fat

Weight lossKetones


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Slide No 6

Clinical features

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Pathophysiology(Whats wrong) Clinical features(What do you see)

Elevated bloodglucose

High lab blood glucose, glucose meterreading or urine glucose, polyuria,polydypsia

Dehydration Sunken eyes, dry mouth, decreasedskin turgor, decreasedperfusion (shock rare)

Altered electrolytes Irritability, change in level ofconsciousness

Metabolic acidosis(ketosis)

Acidotic breathing, nausea, vomiting,abdominal pain, altered level ofconsciousness


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Slide No 7

Managing DKA

Refer to best available site of care whenever possible

Need:

Appropriate nursing expertise (preferably a high level ofcare)

Laboratory support

Clinical expertise in management of DKA

Written guidelines should be available

Document and use the form

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Slide No 8

DKA monitoring form


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DKA monitoring

DKA protocol available to the clinic


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Principles of DKA management (1)

1. Correction of shock

2. Correction of dehydration

3. Correction of hyperglycaemia

4. Correction of deficits in electrolytes

5. Correction of acidosis

6. Treatment of infection

7. Treatment of complications

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Slide No 11

Principles of DKA Management (2)

1. Correction of shock or decreased peripheralcirculation quick phase

2. Correction of dehydration - slow phase

Do not start insulin until the child has beenadequately resuscitated, i.e. good perfusion and

good circulation

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Slide No 12

Principles








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Slide No 13

Assessment

History and examination including:

Severity of dehydration. If uncertain about this, assume10% dehydration in significant DKA

Level of consciousness

Determine weight

Determine glucose and ketones

Laboratory tests: blood glucose, urea and electrolytes,

haemoglobin, white cell count, HbA1c

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Slide No 14

Resuscitation (1)

Ensure appropriate life support (Airway, Breathing,Circulation, etc.)

Give oxygen to children with impaired circulation and/orshock

Set up a large IV cannula/intra-osseous access. Give fluid (saline or Ringers Lactate) at 10ml/kg over

30 minutes if in shock, otherwise over 60 min. Repeatboluses of 10 ml/kg until perfusion improves

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Slide No 15

Resuscitation (2)

If no IV available, insert nasogastric tube or set upintraosseous or clysis infusion

Give fluid at 10 ml/kg/hour until perfusion improves, then5 ml/kg/hour

Use normal saline, half-strength Darrows solution withdextrose, or oral rehydration solution

Decrease rate if child has repeated vomiting

Transfer to appropriate level of care

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Slide No 16

Principles








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Slide No 17

Rehydration (1)

Rehydrate with normal saline

Provide maintenance and replace a 10% deficit over 48hours

Do not add urine output to the replacement volume

Reassess clinical hydration regularly.

Once the blood glucose is


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Slide No 18

Rehydration (2)

If IV/intra-osseous access is not available:

Rehydrate orally with oral rehydration solution (ORS)

Use nasogastric tube at a constant rate over 48 hours

If a NG tube tube is not available, give ORS by oral sipsat a rate of 1 ml/kg every 5 min if decreased peripheralcirculation, otherwise every 10 min.

Arrange transfer of the child to a facility withresources to establish intravenous access as soonas possible

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Principles








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Insulin therapy (1)

Start insulin after your ABCs (treat shock, start fluids) -stability has improved

Insulin infusion of any short acting insulin at0.1U/kg/hour (0.05 U/kg/hr if younger than 5 years)

Rate controlled with the best available technology(infusion pump)

Do not correct glucose too rapidly. Aim for decrease of5 mmol/l per hour

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Slide No 21

Insulin therapy (2)

Example:

A 24 kg child will need 2.4 U/hour

Put 24 U short acting insulin into 100 ml saline and run at10 ml/hour

Equivalent to 0.1 U/kg/hour

Younger children: lower rate e.g. 0.05 U/kg/hour

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Slide No 22

Insulin therapy (3)

If no suitable control of the rate of the insulin infusionis available

OR

No IV access use sub-cutaneous or intra-muscular

insulin. Give 0.1 U/kg of short-acting regular or analogue

insulin subcutaneously or IM into the upper arm

Arrange transfer of the child to a facility withresources to establish intravenous access as soon

as possible

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Slide No 23

Principles








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Slide No 24

Electrolyte deficits

The most important is potassium

Every child in DKA needs potassium replacement

Other electrolytes can only be assessed with alaboratory test

Obtain a blood sample for determination of electrolytesat diagnosis of DKA

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Slide No 25

ECG and Potassium Levels

l dl d


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Slide No 26

Potassium (1)

Levels determined by laboratory test

If not available, can use ECG (T waves)

Start potassium replacement once serum value knownor patient passes urine

If no lab value or urine output within 4 hours of startinginsulin, start potassium replacement

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Slide No 27

Potassium (2)

Add KCl to IV fluids at a concentration of 40 mmol/l (20ml of 15% KCl has 40 mmol/l of potassium)

If IV potassium not available, replace by giving thechild fruit juice or bananas.

If rehydrating with oral rehydration solution (ORS), noadded potassium is needed

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Slide No 28

Potassium (3)

Monitor serum potassium 6-hourly, or as often as ispossible

In sites where potassium cannot be measured,consider transfer of the child to a facility with

resources to monitor potassium and electrolytes

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Principles








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Acidosis

Usually due to ketones

Poor circulation will make it worse

Correction not recommended unless the acidosis is veryprofound

If bicarbonate is considered necessary, cautiously give1-2 mmol/kg over 60 minutes. Usually not needed

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Principles








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Slide No 32

Infection

Infection can precipitate the development of DKA

Often difficult to exclude infection in DKA, as the whitecell count is often elevated because of stress

If infection is suspected, treat with broad-spectrum

antibiotics

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Slide No 33

Principles








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Slide No 34

Complications

Electrolyte abnormalities

Cerebral oedema

Rare but often fatal

Often unpredictable

Related to severity of acidosis, rate and amount ofrehydration, severity of electrolyte disturbance, degreeof glucose elevation and rate of decline of blood glucose

Causes raised intra-cranial pressure

Can lead to death

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Cerebral Oedema (1)

Presents with

Change in neurological state (restlessness, irritability,increased drowsiness or seizures)

Headache

Increased blood pressure and slowing heart rate Decreasing respiratory effort

Focal neurological signs

Diabetes insipidus: unexpected/increased urination



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Cerebral Oedema (2)

Check blood glucose

Reduce the rate of fluid administration by one-third.

Give hypertonic saline (3%), 5 ml/kg over 30minutes - repeat if needed

Mannitol 0.5-1 g/kg IV over 20 minutes may be analternative

Elevate the head of the bed

Nasal oxygen

Intubation may be necessary for a patient withimpending respiratory failure



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Monitoring

Use forms: Record hourly: heart rate, blood pressure, respiratory

rate, level of consciousness, glucose.

Monitor urine ketones

Record fluid intake, insulin therapy and urine output Repeat urea & electrolytes every 4-6 hours

Once the blood glucose is less than 15 mmol/l, adddextrose to the saline

Transition to subcutaneous insulin



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DKA In Summary

Life threatening condition

Requires care at the best available facility

Morbidity and mortality reduced by early treatment

Adequate rehydration and treatment of shock crucial

Written guidelines should be available at all levels ofthe healthcare system

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Questions

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3a Emergency Care DKA (UK) FINAL(2)

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