University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
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Last updated December 8, 2016 3:45 PM

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Noah's Ark Childrens Hospital for Wales
Heath Park
Cardiff
CF14 4XW
02920 747747


Diabetic ketoacidosis


We use the DKA guidlines that the paediatric endocrinology department have produced, and these are the same as the British Society of Paediatric Endocrinology guidelines. These have been recently updated.

New BSPED DKA Guidelines 2009

BSPED DKA Calculator

BSPED DKA Flowchart

The main changes in the new documents are as follows:
1. Recommendation to use capillary blood ketone measurement during treatment. This is not currently routinely available at UHW, but may became available in the future.
2. Reduction in the degree of dehydration to be used to calculate fluids
3. Reduction in maintenance fluid rates
4. Change in the recommendations for PICU/HDU - more emphasis on safe nursing on general wards
5. Continuation of Normal saline for the first 12 hours of rehydration
6. Delay in insulin until fluids have been running for an hour
7. Option to continue insulin glargine during treatment
8. Reminder to stop insulin pump therapy during treatment
9. Reminder to consider anticoagulant prophylaxis in young children, especially those with femoral lines
10. Interpretation of blood ketone measurements if pH not improving
11. Option to use hypertonic saline instead of mannitol for the treatment of cerebral oedema

The Department of Child Health also uses an Integrated Care Pathway for children with DKA on the general wards and HDU. It is not used on PICU.

Background

It is unusual for children with DKA to come to PICU - they are usually looked after in their local hospital or in HDU at UHW. Some of the guidance below is intended more for patients outside PICU

Other aspects of diabetes management are available on the intranet site - only accessible from trust computers - navigate the clinical portal to: child health>paediatric diabetes>clinical guidance

General principles

General considerations

These are general guidelines for management. Treatment may need modification to suit the individual patient and these guidelines do not remove the need for frequent detailed reassessments of the individual child's requirements.
These guidelines are intended for the management of the children who have:
- Hyperglycaemia (BG >11mmol/l)
- pH < 7.3
- Bicarbonate <15mmol/l
and who are:
- more than 3% dehydrated
- and/or vomiting
- and/or drowsy
- and/or clinically acidotic

Children who are 5% dehydrated or less and not clinically unwell usually tolerate oral rehydration and subcutaneous insulin. Discuss this with the senior doctor on call.
Please discuss with the duty Consultant for Paediatric Endocrinology and Diabetes (available through switchboard) if you admit anyone in DKA, either at night if there are problems with management, or the next morning
(bleep the endocrine SpR during the day, or Extn 2274/6374 (consultant secretaries), or mobile phone no 07778142746 out of hours).
If the child is ill (and certainly if the child is admitted to ITU), please inform the duty Endocrine and Diabetes Consultant.

Emergency management

1. General Resuscitation: A, B, C.
Airway:
- Ensure that the airway is patent and if the child is comatose, insert an airway.
- If comatose or recurrent vomiting, insert N/G tube, aspirate and leave on open drainage.
Breathing:
- Give 100% oxygen.
Circulation:
- Insert IV cannula and take blood samples (see below).
- If shocked (poor peripheral pulses, with poor capillary filling with tachycardia, and/or hypotension) give 10 ml/kg 0.9% saline as a bolus, and repeat as necessary to a maximum of 30mls/kg (there is no evidence to support the use of colloids or other volume expanders in preference to crystalloids).
2. Confirm the Diagnosis (if a new patient):
History:
- polydipsia, polyuria
Clinical:
- acidotic respiration
- dehydration
- drowsiness
- abdominal pain/vomiting
Biochemical:
- high blood glucose on finger-prick test
- glucose in urine and ketones in blood and urine.

Near patient blood ketone monitors may be available from Diabaetic Liaison Nurses Extension 5435, but are not currently part of local management in UHW.


3. Initial Investigations:
- WEIGH THE CHILD: If this is not possible because of the clinical condition, use the most recent clinic weight as a guideline or an estimated weight from centile charts.
- blood glucose
- urea and electrolytes (electrolytes on blood gas machine give a guide until accurate results available
- blood gases (preferably arterial or capillary, but venous gives similar pH)
- PCV and full blood count

Other investigations only if indicated e.g. CXR, CSF, throat swab, blood cultures, urinalysis, culture and sensitivity etc.
(DKA may rarely be precipitated by sepsis, and fever is not part of DKA)

Clinical assessment and observations

Assess and record in the notes, so that comparisons can be made by others later.
1. Degree of Dehydration -
- 3% dehydration is only just clinically detectable
- mild, (5%) - dry mucous membranes, reduced skin turgor
- moderate (7.5%) - above with sunken eyes, poor capillary return
- severe, (10% ± shock) - severely ill with poor perfusion, thready rapid pulse, (reduced blood pressure is not likely and is a very late sign).
2. Conscious Level -
- Institute hourly neurological observations whether or not drowsy on admission.
- If in coma on admission, or there is any subsequent deterioration:
- record Glasgow Coma Score (see Appendix)
- transfer to ICU
- consider instituting cerebral oedema management (section F)
3. Full Examination - looking particularly for evidence of:
o cerebral oedema: headache, irritability, slowing pulse, rising blood pressure, reducing conscious level
o infection
o ileus
4. Does the child need to be on ICU? -
YES if:
- intubated
Intubating and ventilating children with DKA is difficult and carries a significant risk of making things worse - if there is time to discuss the patient with PICU prior to intubation, please do so.
5. Observations to be carried out:
Ensure full instructions are given to the senior nursing staff emphasising the need for:
- strict fluid balance and urine testing for ketones of every sample
- hourly BP and basic observations
- capillary blood ketone levels may be available and may be a sensitive measure of suppression of ketogenesis during treatment
- hourly capillary blood glucose measurements (these may be inaccurate with severe dehydration/acidosis but useful in documenting trends. Do not rely on any sudden changes but check with a venous laboratory glucose measurement)
- twice daily weights can be helpful in assessing fluid balance
- hourly or more frequent neuro observations initially
- reporting immediately to the medical staff, even at night, symptoms of headache or any change in either conscious level or behaviour
- reporting any changes in the ECG trace, especially T wave changes

 

  • Fluids
  • Potassium
  • Insulin
  • Phosphate
  • Bicarbonate
  • Cerebral Oedema

The signs and symptoms of cerebral oedema include:

  • headache & slowing of heart rate
  • change in neurological status (restlessness, irritability, increased drowsiness, incontinence)
  • specific neurological signs (eg. cranial nerve palsies)
  • rising BP, decreased O2 saturation
  • abnormal posturing

More dramatic changes such as convulsions, papilloedema, respiratory arrest are late signs associated with extremely poor prognosis


Management :

If cerebral oedema is suspected inform senior staff immediately.
The following measures should be taken immediately while arranging transfer to PICU–

  • exclude hypoglycaemia as a possible cause of any behaviour change
  • give hypertonic (2.7%) saline (5mls/kg over 5-10 mins) or Mannitol 0.5 – 1.0 g/kg stat (= 2.5 - 5 ml/kg Mannitol 20% over 20 minutes). This needs to be given as soon as possible if warning signs occur (eg headache or pulse slowing).
  • restrict IV fluids to 1/2 maintenance and replace deficit over 72 rather than 48 hours
  • the child will need to be moved to PICU (if not there already)
  • discuss with PICU consultant. Do not intubate and ventilate until an experienced doctor is available
  • once the child is stable, exclude other diagnoses by CT scan - other intracerebral events may occur (thrombosis, haemorrhage or infarction) and present similarly
  • a repeated dose of Mannitol may be required after 2 hours if no response
    document all events (with dates and times) very carefully in medical records