DKA in children

Diabetic Ketoacidosis   in Children
 

                                       Presented By:

                     Dr.Md.  Maniruzzaman

                             
 Definition :

It is a Clinical Condition in children Having-

•Hyperglycemia (BG >11mmol/L) , Heavy glycosuria & Dehydration (5% or more)

•Acidosis: pH <7.3 and/or Bicarbonate <15mmol/L

•Kitosis: Ketonemia and Ketonuria

•With or without Vomiting  & Drowsiness

 Classification of DKA

	Normal	MILD	MODERATE	SEVERE
pH	7.35-7.45	7.25-7.35	7.15-7.25	<7.15
CO2 (meq/l)	20-28	16-20	10-15	<10
Clinical	No change	Oriented, alert but fatigued.	Kussmaul respirations; oriented but sleepy; arousable.	Kussmaul or depressed respirations; sleepy to depressed sensorium to coma.

	Normal	MILD	MODERATE	SEVERE
pH	7.35-7.45	7.25-7.35	7.15-7.25	<7.15
CO2 (meq/l)	20-28	16-20	10-15	<10
Clinical	No change	Oriented, alert but fatigued.	Kussmaul respirations; oriented but sleepy; arousable.	Kussmaul or depressed respirations; sleepy to depressed sensorium to coma.

Causes of DKA

§Insulin deficiency, either relative or absolute.

  ● Failing to take insulin, particularly in           adolescents.

   ●  Too little insulin is given because of fear of            hypoglycemia.

     ● Insulin is omitted altogether by an           emotionally disturbed adolescent or with      menstruation or severe emotional upset.

       Risk factors of DKA

•Children with poor metabolic control or previous episode of DKA.

•Female gender (peripubertal or adolescent).

•Psychiatric & behavioral disorders.

•Children with limited access to medical service .

•Insulin pump therapy.

•Acute stress, like trauma, infections with elevated counter regulatory hormones.

Management of DKA:
Emergency Assessment

•Characteristic history-polydipsia, polyuria.

•Nausea, vomiting and abdominal pain.

•Followed by unconsciousness.

•Severity of dehydration.

•Evidence of acidosis.

•Assessment of conscious level-GCS.

•Weight.

•Blood glucose.

•Urine for sugar and ketones.

Resuscitation:

In shock with poor peripheral pulses or coma

•Oxygen 100% by mask.

•20ml/kg (0.9% Nacl) boluses infused quickly

•Normal saline 10ml/kg/hr, repeated if peripheral pulses remain poor (Max. 3times).

•Nasogastric tube to drain stomach.

•Urinary catheter.

•Antibiotics to febrile pt. after obtaining culture.

Key Findings : Clinical 

•Polyuria, Polydipsia , Polyphagia.

•Nausea, Vomiting and Abdominal pain.

•Dehydration.

•Weakness, Weight loss.

•Progressive loss of consciousness, convulsion.

•Rapid,deep,sighing (Kussmaul) respiration.

Fruity odour of ketones on the breath. 
Key Findings : Biochemical

Always present:

•Hyperglycemia, Glycosuria.

•Ketonemia, Ketonuria.

•Metabolic acidosis/acidemia

•Hypocarbia (compensatory)

Sometimes present:  

•  Apparent or actual hyponatremia  

•  Hypernatremia   

•  Hyperkalemia or hypokalemia

•  Hypophosphatemia  

•  Increased blood urea nitrogen   

•  Increased serum creatinine

•  Hyper triglyceridemia   

•  Increased serum amylase

Acidosis and bicarbonate :

Why not use bicarbonate?

ØDecrease in tissue perfusion.

ØIncreased risk of hypokalemia.

ØDoes not hasten resolution of acidosis (other  

than very short term).

ØMay result in increased hepatic ketone production.

ØMay result in CNS acidosis.

ØIncreased risk of cerebral edema.

Complications of DKA

ØClinically-evident cerebral edema: ~ 0.5-1%

ØHypoglycemia

ØHypokalemia or Hyperkalemia

ØHyperchloremic acidosis

ØHypophosphatemia

ØCNS complication-DIC, thrombosis.

ØSepsis

ØAspiration pneumonia

ØPulmonary edema

ØAcute renal failure

Cerebral edema

ØApproximately 0.5-1.5% children presenting with DKA develop cerebral edema with a high mortality and morbidity.

ØThose who developed CE in DKA

    64%-died, 13%-severe disability, 9%-minor disability and 14% survived without disability.

Ø CE most commonly occurs in the first 24 hrs. and is present both at presentation and during DKA treatment.

Warning signs / symtoms of CE

ØHeadache & slowing of heart rate.

Ø

ØChange in neurological status(restlessness, irritability, increased drowsiness, incontinence).

Ø

ØRising BP, decreased O2 saturation

Ø

ØConvulsions, papilloedema, respiratory arrest are late sings