DKA 2022- a Sweet New Year to All

The latest CHOP Pediatric Emergency Medicine PODCAST features renowned clinicians/researchers Dr. Nicole Glaser and Dr. Nathan Kuppermann discussing their lifetime journey studying DKA — a must listen to episode!

EVIDENCE-BASED Literature

What are the RISK FACTORS for developing cerebral edema in children with DKA - Drs. Glaser/Kuppermann and colleagues tell you what they are…and what they are NOT!

Fluid rates and composition in the treatment of DKA…does it contribute to brain injury—the LANDMARK study a click away!

A brief Q and A from our DKA experts Dr. G and Dr. K from UC Davis Health

CLINICAL PEARLS

Children’s Hospital of Philadelphia DKA Clinical Pathway

BREAKING NEWS: Thanks to Drs. Pam Okada, Sing-yi Feng and Craig Huang [editors of PEM Question Review book], we will now be bringing you access to PEM Board-Review questions in each newsletter. Please clink on this LINK to see info re: the MEDCHALLENGER PEM Board Review course/materials.

Q: A 12 yo male is being transferred to your facility by your hospital-based pediatric transport team. He has just been diagnosed with diabetes mellitus and is coming to your tertiary care referral center for subspecialty care. On arrival at the outside hospital, the transport team contacts you that he is alert and oriented x 3. His T is 37°C, HR 110, RR 24, BP 110/70, and pOx 98% on RA. His weight is 50 kg. His capillary refill time is 3 seconds. Other than his deep respirations, the rest of his exam is normal. His initial labs include: Na 130, K 4.1, Cl 102, CO2 8, BUN 20, Cr 0.7, and glucose 720. His urinalysis is positive for ketones. He has already received an initial normal saline fluid bolus of 500 cc. The transport team has the ability to do an insulin drip and manage glucose en route. What initial IV fluid and insulin drip rate orders do you request for this 2-hour ground transport? 

a.                    ½ NS + 40 mEq/L KCl 90 mL/hr + insulin 0.5 units/hr 

b.                    ½ NS + 40 mEq/L KCl 90 mL/hr + insulin 5 units/hr 

c.                    ½ NS + 40 mEq/L KCl 175 mL/hr + insulin 0.5 units/hr 

d.                    ½ NS + 40 mEq/L KCl 175 mL/hr + insulin 5 units/hr 

e.                    3% saline at 90 mL/hr + insulin 0.5 units/hr 

Answer: d. ½ NS + 40 mEq/L KCl 175 mL/hour + insulin 5 units/hr. Although the fluids used in treating diabetic ketoacidosis (DKA) are subject to institutional variation and are currently under investigation, the goals of resuscitation include: correct dehydration, correct acidosis and reverse ketosis, restore blood sugar to near normal, avoid complications of therapy, and identify and treat any precipitating event. Current recommendations include IV fluid replacement at 1.5-2 times the maintenance rate (135-180 mL/hr for this 50 kg patient) and insulin at 0.1 units/kg/hour (5 units/hour). Hypertonic saline is not an appropriate fluid for resuscitation in a patient with DKA, unless he is showing signs of cerebral edema. 

Q: A 12 yo male is being transferred to your hospital via your hospital-based pediatric transport team for the diagnosis of new onset diabetes with diabetic ketoacidosis. Prior to contacting your facility for transport, the patient had been given 2 normal saline boluses of 20 mL/kg and sodium bicarbonate 1 mEq/kg. Upon arrival at your hospital, the transport team reports no issues during transport. On your exam in the ED, you note that the patient is now very difficult to arouse and has urinated on himself. His T is 37ºC, P 60, RR 26, BP 130/90, and pOx 98% on RA. The rest of his exam shows an intact gag reflex, normally reactive pupils, no disconjugate gaze, and continued deep respirations. His last glucose check 5 minutes before arrival was 350. What should be done next? 

a.                    Recheck blood gas and urine ketones 

b.                    Increase the insulin drip rate 

c.                    Obtain non-contrast CT of the brain 

d.                    Administer a normal saline 20 mL/kg bolus 

e.                    Administer a 3% saline bolus 

Answer: e. Administer a 3% saline bolus. This patient is demonstrating signs of cerebral edema and needs immediate treatment with either hypertonic saline or mannitol to prevent herniation. Identifying and treating cerebral edema takes priority. Further isotonic IV fluids or laboratory testing are not indicated at the moment. There is no need to increase the insulin drip rate at this time. Radiographic signs of cerebral edema may lag behind clinical signs, and therefore a CT scan is not as helpful. Thus, cerebral edema in DKA remains a clinical diagnosis requiring one of the following: 1 diagnostic criterion; 2 major criteria; or 1 major plus 2 minor criteria: 

Diagnostic criteria 

·                     Abnormal motor or verbal response to pain  

·                     Decorticate or decerebrate posturing  

·                     Cranial nerve palsy (especially III, IV, and VI)  

·                     Abnormal neurogenic respiratory pattern (e.g., grunting, tachypnea, Cheyne-Stokes respiration, apneusis)  

Major criteria  

·                     Altered mentation/fluctuating level of consciousness  

·                     Sustained heart rate deceleration (more than 20 bpm) not attributed to improved intravascular volume or sleep state  

·                     Age-inappropriate incontinence  

Minor criteria  

·                     Vomiting  

·                     Headache  

·                     Lethargy or being not easily aroused from sleep 

·                     Diastolic blood pressure >90 mmHg  

·                     Age < 5 years