Diabetic ketoacidosis
DKA
| Headline | |
|---|---|
| Etiology | any metabolic stressors: infection, trauma, surgery... |
| Epidemiology | |
| Clinical presentation | Diagnostic criteria: 1. hyperglycaemia (CBG >11 or known DM) 2. ketonaemia (blood ketones > 3) 3. acidosis (pH <7.3 or HCO3 <15) (HAGMA) > Pitfalls: Fever, ↑CRP is not part of DKA! |
| Pathogenesis | |
| Diagnostic investigations | Diagnostic criteria ➥ ketones > 3.0mmol/L OR ≥2+ ketonuria; AND ➥ bicarb < 15.0 and/or VBG pH <7.3 ➥ CBG >11.0 or known DM See also Hyperosmolar hyperglycaemic state Immediate: blood gas, ECG |
| Management | see one-pager. Aims (BNF treatment summary): - restore circulatory volume - correct electrolyte imbalance and hyperglycaemia - clear ketones and suppress ketogenesis - identify and treat any precipitating causes, and prevent complications. Insulin rate: 0.1 units/kg/h (50 units actrapid in 50ml 0.9% NaCl = 1 unit/ml) Specific treatment targets: - ketones <0.6 - pH >7.3 or HCO3 >18 - replace K if 3.5-5.5 - replace glucose if glucose <14mmol/L Resolution defined as pH >7.3 and/or ketones <0.3bru |
fluid resuscitation
fluid deficit in children - BSPED
Basically moved away from an overly restrictive fluid resuscitation strategy (PECARN 2018)
Assume a 5% fluid deficit in children and young people in mild DKA
- blood pH 7.2-7.29 &/or bicarbonate <15
Assume a 5% fluid deficit in children and young people in moderate DKA
- blood pH of 7.1- 7.19 &/or bicarbonate <10
Assume a 10% fluid deficit in children and young people in severe DKA
- blood pH <7.1 &/or bicarbonate <5
10ml/kg bolus - take away from calculated fluid deficit IF NOT SHOCKED
5% or 10% * weight = volume over 48h → use to derive rate in ml/h
Maintenance rates = Holliday-Seager formula
i.e. 100ml/kg/day for 1st 10 kg, 50ml/kg/day for next 10kg, 20ml/kg/day for subsequent
derive rate of fluids (ml/h)