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Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
Diabetic Ketoacidosis in children
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Diabetic Ketoacidosis in children

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  • 1. DIABETIC KETOACIDOSIS-Management  Dr.Abhijeet
  • 2.  Charisma a 11 yr old girl brought to casualty with c/o drowsiness, abdominal pain, Fast breathing ,nausea & vomiting with weight loss 3-4 kg in 2 weeks. She had h/o high grade fever 4-5 days back & treated with Antibiotics in other hospital. All blood investigations were done there except GRBS.
  • 3.  O/E : She was severely dehydrated with acidotic breathing /tachypnoea & in state of altered consiousness.
  • 4.  Monitoring and Investigations:-Moderate-severe DKA- Admit in ICU.-Hrly HR,RR,BP, Spo2, GCS-Monitor for warning signs of cerebral edema : Headache, bradycardia, recurrent vomiting, altered sensorium, CN palsies, abnormal pupillary response.
  • 5.  LAB TESTS:-Hrly GRBS, Blood gas Q4H, Sr electrolytes-Q4H,-Blood urea, creat.-Q12HOn admission:Charisma’s GRBS was 623mg/dl,ABG: pH-6.3, HcO3-6.7
  • 6.  MANAGEMENT: 1. IV Rehydration: -Check for level of dehydration -If shock signs +, give Bolus NS 0.9% 10 ml/kg over 30 min. -Initial fluid boluses are not required if no signs of shock.Maintainence Fluid:<10kg - 100ml/kg/day10-20kg- 1000ml + 50ml/kg for each kg> 10kg>20 kg - 1500ml + 25ml/kg for each kg >20 kg
  • 7. Eg : for 35 kg childMaintainence fluid :(85ml x 35kg) + 1875 ml– Bolus /23=ml/H =119 ml/HrMax fluid over 24 hr -4L/m2 -Underhydration is safer than overhydration.
  • 8. -Start rehydration with NS over 48 hrs.-Strict fluid balance charting every few hrs.2. Acidosis correction & Bicarbonate therapy: -DKA patients have wide Anion gap metabolic acidosis d/t excess of Ketones & Lactate -Use of Bicarb therapy is contravercial as it may cause Paradoxical CNs acidosis, Hypokalemia, Increased Na load & sudden rise in Sr osmolality.
  • 9.  Indications of Bicarb Therapy--PH<7-Refractory shock-Life threatening hyperkalemia HCO3 required in mmol = 0.3 X Wt.in KgX Base deficitGive half of calculated bicarb. Over 4 Hrs by slow infusion then reassess Blood gas, cease when Ph<7
  • 10.  Potassium replacement:- DKA Patients have profound total body potassium deficit d/t polyurea . Hypokalemia worsens with hydration & Insulin.- K+ Replacement should begin prior to commencing the insulin infusion, after initial fluid bolus.- Start K+ at the rate of 5meq/kg/day. reassess K+ every 2 Hrs for 1st 6 Hrs then every 4 Hrly.
  • 11. -Aim to maintain K+ > 4-4.5 m eq/L. Insulin infusion:- Start after correction of shock.- Start at 0.05-0.1 units/kg/hr.- Aim to fall Blood glucose at 100mg/dl/hr.- Titration of Insulin:- Adjust insulin infusion rate to keep BSL between 100- 200mg/dl.
  • 12. - Decrease insulin infusion rate by 50% if BSL fall is > 100mg/dl/hr- Increase insulin rate by 50% if BSL fall is <100mg/dl/hr- Change IVF to ½ NS + D5% when BSL falls below 300mg/dl.
  • 13.  Cerebral edema- It is the sudden unexpected complication of therapy of DKA which occurs during 1st 24 Hrs of t/t, usually when metabolic parameters are normalizing.- Monitor GCS.- Mannitol 1-1.5 gm/kg by rapid IV infusion aiming to rise Sr osmolality by 5-10 m osm/kg & decrease cerebral edema.
  • 14.  Treatment of precipitating infections if present.-Urine & Blood c/s done to rule out any focus of infection.- Start impirical antibiotics if Raised blood Total counts persisting or active focus of infection present.
  • 15.  Oral feeds-- Kept NPO till metabolically stable, i.e(BSL<200, pH> 7.3, HCO3>15mmol/L). Stopping of IV Insulin:- When child is alert & Metabolically stableMost convinient time to chance to SC insulin is just before meals.
  • 16.  Suggested Schedule:- SC insulin 30 min before meal meal + insulin infusionstop infusion 90 min after SC dose.- Usual total daily dose is 1 U/Kg/day.- May require modification as per BSL values.
  • 17. - If the metabolic state is not attained correctly, The ‘SEVENTH’S SCALE insulin regime can be started : Short acting insulin given Q6H with 2/7th total daily dose given before breakfast, 2/7th before Lunch, 2/7th before evening food & 1/7th without food at midnight
  • 18.  If child;s metabolic state is normal, proceed directly to ‘Combined insulin regimen’:- Combination of Long+ Short acting insulin given BD, 30 min prior to morning & evening meals i.e. 2/3rd of total daily insulin in morning & 1/3rd prior to Dinner.- BSL may be checked ½ Hr prior & 2 Hrs after each meals.
  • 19. THANK YOU !

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