Diabetic Ketoacidosis in Children - An Intensivist's Perspective for the Emergency Medicine Provider - CECentral

Diabetic Ketoacidosis in Children
An Intensivist’s Perspective for the Emergency
Medicine Provider

September 12, 2020

Ashwin Krishna MD, MPH, FAAP
Assistant Professor of Pediatrics
PICU/PCU Medical Director
University of Kentucky College of Medicine
Kentucky Children’s Hospital

Disclosure

I have no financial disclosures or conflicts of interest to report

Overview

• Epidemiology, Pathophysiology and Definition

• Risk Factors for Life Threatening Disease

• KCH DKA guideline

• Role of the Community Hospital Provider

DKA
•   Leading cause of morbidity and mortality in patients with Type 1 Diabetes Mellitus (T1DM)

•   Occurs at the time of diagnosis in 30% of Children in US and Canada

•   Risk factors for DKA as initial presentation of T1DM:
       •   Age

Pathophysiology

T1DM: β-islet cells in pancreas cannot
make insulin

T2DM: Hepatocytes, adipose tissue and
skeletal muscle cannot respond to secreted
insulin

                                             Cohen et al. Major Topics in Type 1 Diabetes. Published November 2015

Definition of DKA

DKA                                                                                  HHS
• Hyperglycemia—Serum Glucose                                                        • Severe hyperglycemia—Serum
  >200 mg/dL (11mmol/L)                                                                glucose>600mg/dL (>33.3mmol/L)
• Metabolic Acidosis with elevated
  anion gap                                                                          • Mild acidosis
   • Venous pH 7.25
   • Serum bicarbonate 3mmol/L                                                                      osmolality (>320mOsm/L)
   • Urine ketones of moderate/large is
     sufficient in the presence of the
     other 2 criteria

                                     Zeitler P, Haqq A, Rosenbloom A, et al. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr 2011; 158:9.
                             Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155.

Some quick calculations
Anion Gap= (Serum Na+) – (Cl- + HCO3-)

Serum Osmolality= 2(Serum Na+) + (BUN/2.7) + (Glucose/18)

MUDPILES
Methanol Tox.
Uremia
DKA
Paraldehyde/phenformin
INH/Iron Tox
Lactic Acidosis
Ethylene Glycol
Salicylates

DKA—Fluid Status and Acidosis

• Fluid status—generally have 5-10% fluid deficit
  • Reasonable to assume 7% fluid deficit in moderate/severe DKA
  • Measure weight loss from pre-illness status

• Acidosis
  • Mild DKA pH 7.2-7.3
  • Moderate DKA pH 7.1-7.19
  • Severe DKA pH

DKA—Ketones and Electrolytes

  Ketones
     Serum BOHB—most accurate clinical test for ketosis
     Urine Ketones—can confirm presence but not severity
     Anion Gap—useful surrogate if BOHB not available. Abnormal ≥15

  Electrolytes
     Sodium deficit almost always present, but serum sodium concentrations can vary
          Hyperglycemia increases serum osmolalitywater moves to extracellular space via
          osmotic gradientNa+ diluted
          Glucosuria induces osmotic diuresisincreased water lossraises serum sodium
     Potassium deficit though levels are usually normal or high
          K moves into extracellular space
          Insulin (when you start it) moves K intracellularly so anticipate replacement
     Phosphate balance negative due to poor diet and decreased intake—however often normal
     levels in serum
          Osmotic diuresis causes phosphaturia
          Insulin (when you start it) moves Phos intracellularly so anticipate replacement

DKA—Presentation

• Polyuria—presents differently at different ages
• Polydipsia
• Weight loss
    • Anorexia (initially)                                                            Considerations/Red Flags
    • Nausea/Vomiting                                                                 • New onset enuresis in a
    • Abdominal Pain
                                                                                       previously toilet trained child
• Candida infections
• Hyperventilation—compensation for metabolic acidosis                                • Younger children may not have
    • Tachypnea                                                                         apparent polyuria/polydipsia if they
    • Deep, heaving breaths (Kussmaul Respirations)
    • Ketone breath                                                                     are not toilet trained
• Dehydration
    • Tachycardia                                                                     • Dehydrated patients don’t have
    • Poor perfusion                                                                    polyuria!!!
    • Decreased skin turgor
• Mental Status Change (late)
    • Drowsiness
    • Lethargy
    • Coma

                                                 Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic
                                                 hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155.

Initial Assessment and Treatment

Assessment of the DKA Patient                 Treatment of the DKA Patient
• ABCs
• Vital Signs                                 • Gentle isotonic volume
• Mental Status                                 expansion (limit fluid bolus to
• Evaluate for Evidence of Infection            10-20mg/kg) based on fluid
• Obtain weight—compare with pre-               status
  illness weight if possible                  • Initiation of an insulin infusion
• Labs:                                         (.05-0.1u/kg/hr)
   •   Fingerstick Glucose
   •   VBG—assess severity of acidosis        • Initiation of hourly fluids at
   •   BOHB—best direct test
   •   Urine Ketones                            supramaintenance but not
   •   Full chemistry panel, including phos     excessive rate

DKA—Cerebral Edema

• 1% of children with DKA
• 40-70% mortality
• Most common cause of death from Diabetes

This Study:
• Retrospective Case Control
• 61 patients identified with Cerebral Edema and DKA
• 174 Matched controls by age, sex, new onset vs known
• 181 randomly selected controls

Other Risk Factors
• Overadministration of fluid (>50ml/kg in first 4hrs)
• Age

DKA—Cerebral Edema

 • Hypocapnia—cerebral
   vasoconstriction

 • Dehydration

 • Osmotic Changes with
   correction

 • Bicarb: promotes osmotic shifts
   and cellular swelling AND
   precipitously drops serum K

              RISK FACTORS FOR CEREBRAL EDEMA IN CHILDREN WITH
              DIABETIC KETOACIDOSISN Engl J Med, Vol. 344, No. 4

DKA—Cerebral Edema

• Multi-center RCT

• 1389 DKA admissions

• Children were randomly assigned to
  one of four treatment groups in a 2-
  by-2 factorial design
    • 0.9% NaCl vs 0.45% NaCl solution
    • Rapid versus Slow administration

• No Differences in complications or
  cerebral edema for either the fluids
  or rate of replacement

                                         RISK FACTORS FOR CEREBRAL EDEMA IN CHILDREN WITH
                                         DIABETIC KETOACIDOSISN Engl J Med, Vol. 344, No. 4

DKA at KCH

• First KCH guideline created 2014
• Revised in 2019
• Reviewed by Critical Care and Endocrinology teams at KCH

Goal: Prevent complications with either aggressive correction or
administration of therapeutics with a high risk of CE

DKA at KCH

• Inclusion and Exclusion
 Criteria

• Goals of Care

DKA at KCH

DKA at KCH

DKA at KCH—Management

• Insulin Drip (.05-0.1unit/kg/hr)

• 2 bag system
    • Without dextrose
    • With dextrose

• 1.5x Maintenance
    • 40/20/10 rule
    • For adult sized patients can
    run at 150ml/hr

    • Q1h fingerstick glucose
    • Repeat BMP in 4 hours if no
    K in fluids
    • Q8h labs otherwise or thereafter

DKA at KCH—Transitioning off Drip

         •   Transition with normal mental status AND:
         •   AG≤16 OR
         •   BOHB

DKA—Transitioning off drip

Future Plans with DKA

• Data reporting metrics

• Revision every 3-4 years based on new evidence

• Bedside BOHB testing—fingerstick + rapid turnaround time

• Outreach—We want to sync our practice with community
  providers

Take Home Points for the Community Provider

                                        Community Provider
                                        Recommendations:
 • No need to ever give a patient
                                        • Primary and Secondary Assessment
   in DKA:                              • Obtain VBG, BMP, UA, BOHB if
   • Sodium Bicarbonate                   possible
   • Insulin bolus (can lead to rapid   • Single (10-20ml/kg) fluid bolus with
     drop in serum glucose)               isotonic crystalloid
                                        • Initiate Insulin infusion at .05-.1
   • Excessive fluids (>20ml/kg           units/kg/hr
     unless in shock)                   • Initiate 2 bags of fluids at 1.5x
   • Any other adjunctive                 maintenance rate
     medications                           • D10 ½ NS or NS with Kphos/KCl
                                           • ½ NS or NS with Kphos/KCl
                                        • Q1h glucoses while on drip
                                        • If pH

Thanks