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.
O/E : She was severely dehydrated with acidotic breathing /tachypnoea & in state of altered consiousness.
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.
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
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
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.
-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.
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
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.
-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.
- 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.
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.
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.
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.
Suggested Schedule:- SC insulin 30 min before meal meal + insulin infusionstop infusion 90 min after SC dose.- Usual total daily dose is 1 U/Kg/day.- May require modification as per BSL values.
- 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
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.