SEMINAR PRESENTATION ON
MANAGEMENT OF DIABETIC KETOACIDOSIS
BY:Kelil kedir (CII)
MODULATORS:
Dr. kemal (MD, Assistant Professor Of Pediatrics And Child health)
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Outline
Introduction
Epidemiology
Pathophysiology
Diagnosis
Treatment
Diagnosis & management of complications of DKA
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Introduction
Diabetic ketoacidosis(DKA)
DKA is a complex metabolic state of hyperglycemia, ketosis,
and acidosis
occurs when there is profound insulin deficiency
life-threatening and needs immediate treatment
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Epidemiology of DKA
DKA characteristically occur in type 1 DM, also can occur in
type 2 DM but less common at presentation of type 2 DM
Occur in 20-40 % in new onset type 1 DM
65% of all admission of DM < 19 yrs of age.
Mortality rate 0.15% in children of which 25% is due to
cerebral edema.
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DKA Risk Factors
Young children
Poor diabetes control
Previous episodes of DKA
Missed insulin injections
Insulin pump failure
Infection or other illnesses
Low socioeconomic status
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Pathophysiology of DKA
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Clinical feature
Polydipsia
Polyuria
Wt. Loss
Abdominal pain
Vomiting
Fast breathing
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Classic Triad of DKA
Hyperglycemia - blood glucose greater than 200 mg/dL
Ketosis - ketones present in blood and/or urine
Acidosis - pH less than 7.3 and/or
bicarbonate less than 15 mmol/L
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Classification of DKA
NORMAL MILD MODERATE SEVERE
CO2 (mEq/L, 20–28 16–20 10–15 <10
venous)
pH (venous) 7.35–7.45 7.25–7.35 7.15–7.25 <7.15
Clinical No change Oriented, Kussmaul Kussmaul or
alert but respirations; depressed
respirations;
fatigued oriented but sleepy to
sleepy; depressed
arousable sensorium to
coma
Approach to patient
History in new diabetic
Recent history of Polyuria Polydipsia Polyphagia &
Weight loss
Past medical history
Family history of diabetes
History/duration of symptoms
Precipitating factors
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History known diabetic
History of diabetes and duration
Last meal/carbohydrate intake
Current and routine blood glucose levels
Standard insulin regimen, last insulin dose, and if missed
insulin dose Illness
Past hospitalization history Duration of symptoms
Precipitating factors
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Physical Assessment
Assess for dehydration
Vital signs, mucous membranes, capillary refill, skin (color,
temperature )
Assess for acidosis
Fruity breath odor
Deep, rapid breathing → Kussmaul’s respirations
Assess mental status
Assess for signs/symptoms of possible infection
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Laboratory Evaluation
Blood glucose CBC
Urine analysis [ketones, Osmolality
glucose] Hemoglobin A1c
blood gas CXR, non-contrast
Electrolytes Head CT, Cultures
BUN, creatinine (blood, urine, throat
DKA Complications
Dehydration CNS Hemorrhage or
Hypoglycemia Thrombosis
Hypokalemia Cardiac Arrhythmias
Cerebral Edema Pancreatitis
Pulmonary Edema Renal Failure
MANAGEMENT
PRENCIPLES OF MANAGMENTS OF DKA
1. ADMISSION
2. RESUSCITATION AND FLUID MANAGMENT
3. INSULIN THERAPY
4. ELECTROLYTE MANAGMENT
5. CORRECTING METABOLIC ACIDOSIS
6. FOLLOW UP AND MONITORING
7. TREAT PRECIPITATING FACTORS AND TREAT
COMPLICATIONS
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1 Admission
ETAT/WARD
o Mild DKA
GCS>8
PH>7.25
No shock
PICU
o Moderate to severe DKA
GCS<8
PH<7.25
Shock
Age <2 yrs.
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2 RESUSCITATION AND FLUID MANAGMENT
The patient should not be given oral fluid until ketone is
resolved, and no vomiting and nausea
IV fluids
Phase I
Initial volume expansion
Phase II
Replacement of fluid deficit
Maintenance fluids
IV fluids first started is either NS or RL .
20ml/kg bolus in the first hour
If the child has good urine out put and intravascular volume, start the next
management
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Cont…
Mild DKA – Deficit 5% of body weigh [50 ml]
Moderate DKA – Deficit 5-7 % of body weight
Severe DKA – Deficit 7 -10% of body weight
Average fluid deficit for moderate to severe DKA is 85 ml
IV Rate = (85ml/kg +MF) – Bolus
48 hours
Oral fluids should be introduced only when substantial
clinical improvement has occurred
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o Types Fluids
Initially use 0.9% NS until serum glucose is below 250 -
300mg/dl
If blood glucose has fallen from 90 - 250 mg/dL Use 0.45%
NS with 5% dextrose..
If serum glucose is < 90mg/dl Use 10% dextrose solution.
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3 INSULIN THERAPY
Insulin should be started 1 hour after starting fluid
replacement.
The initial dose of regular insulin is 0.05 - 0.1unit/kg/hour.
Usually, start with 0.05unit/kg/hr and increase to 0.1unit/kg/hr.
IV bolus is unnecessary, and may increase the risk of cerebral
edema.
50-75 mg/dl/hr is target
Do not correct glucose too rapidly.
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4 Transition to Subcutaneous Insulin Injections
Consider with laboratory & clinical improvement
No emesis, able to tolerate PO, improved mental status and
Urine ketone free
Give insulin every 6 hours 0.5 IU/kg Subcutanous except
the first dose give 1/2 IM and 1/2 Iv then BID base when
acidosis base
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Maintenance – highly variable roughly 0.6 to 0.7
units/kg/day
Regular insulin(30%) 1/3rd +Lente insulin (70%) 2/3rd
-Given subcutaneously
2/3rd morning,
1/3 evening dose
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5 Potassium replacement therapy
When initial serum potassium is <3.5 mmol/L
Administer 0.5-1 mEq/kg of potassium chloride in IV
before insulin therapy
If serum potassium is in normal range (3.5 -5 mmol/L)
Start replacing potassium after initial fluid resuscitation
and concurrent with starting insulin therapy
40 mEq/L in IV solution to maintain serum potassium 3.5
-5 mmol/L
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6 Clinical monitoring
DKA follow up sheet
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Nutritional Mangement
55% CHO,30 %fat and 15 % protein
The total daily caloric intake is divided to provide
20% breakfast, 20% lunch, and 30% dinner,
leaving 10% for each of the midmorning, mid afternoon,
TARGET BG
80 mg/dL in the fasting state to 140 mg/dL after meals.
In practice, however, a range of 70–250 mg/dL is acceptable
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7 DKA complication management
Cerebral edema
The incidence varies from 0.5% to 6%.
Mortality up to 25%.
Typically occurs 4-12hrs after initiation of Rx
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RISK FACTORS
Elevated BUN at presentation.
Severe acidosis at presentation.
Bicarbonate treatment for correction of acidosis.
Hypernatremia
High volumes of fluid given in the first 4 hrs.
Administration of insulin in the first 1 hour of fluid
treatment.
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Diagnosis criteria
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o Diagnostic Criteria
1 diagnostic or 2 major or 1 major and 2 minor criteria
o Treatment
Intranasal oxygen.
Elevate the head of the bed
Reduce the rate of fluid administration by one-third.
Give mannitol:
0.5–1g/kg IV over 20 minutes.
Repeat if there is no initial response in 30 min to 2 hours.
Hypertonic saline ; 5–10 mL/kg over 30 minutes
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HYPOGLYCEMIA
In children with insulin-treated diabetes,
hypoglycemia is defined as a glucose level of ≤70 mg/dL.
In mild hypoglycemia
Sweet drink
Sucrose or fructose containing juices can be used.
Milk and chocolate can delay the absorption of glucose
due to their fat content should be avoid
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cont.....
In severe hypoglycemia
IV/IM/SC glucagon 10–30 µg/kg body weight.
If glucagon is unavailable, intravenous dextrose can be used 200–
500 mg/kg given slowly.
A dextrose concentration of 50% and above or rapid administration
should be avoided.
After the initial bolus of dextrose a slow intravenous infusion of
10% dextrose at a rate of 2–5 mg/kg/min may be required
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INFECTIONS
DKA patients at higher risk of infection.
Most common
Skin: staphylococcal folliculitis, cellulitis,
superinfected fungal infection
Urinary Tract: genital candidal infections, urinary
tract infections & acute pyelonephritis
We have to treat accordingly
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Reference
• Nelson text book pediatrics 21th edition
• ETAT Protocol,2014
• National training on DM guidline,2016
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THANK
YOU
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