Diabetic Ketoacidosis (DKA)
Definition:
- blood glucose >300
- serum bicarbonate <15
- arterial pH<7.30
- Ketonemia >3mml/dl or ketonuria
Laboratory:
Immediate bedside tests:
- Finger Glucose Stick
- urine ketones
Send to lab:
- chem. 10
- VBG, amylase, serum osmolality, CBC with diff
- Hgb A 1c, urinalysisdl
- Calculate serum osmolality: (Na + K mEQ/L) x 2 + (glucose mg/dl)/18
If new onset also need:
- islet cell antibodies, total insulin
- insulin auto antibodies
- anti-GAD antibodies
- C-peptide
Fluids:
1) Start 2 Large bore IVs
2) Initial bolus – 10 ml/kg NS (unless in shock)
Maintenance Fluids – Normal Saline
- If Potassium is >5 no K
- If <5 then 20 Kphos + 20 KCL mEq/L
- Then 1.5 X maint with NS
3) NPO except ice chips
Insulin: (to begin only after electrolytes known and fluid bolus completed)
Preparation – mix regular insulin 50 units into 500 ml of NS
Dose – start with 0.1 units/kg/hr= 0.1 U/ml
- titrate to maintain glucose rate of fall 50-100 mg/dl/hr
Change – add dextrose (D5) onto IVF when blood glucose is 250-300 (if continued acidosis, may need D7.5 or D10). Thereafter, decrease insulin to ½ rate to maintain blood glucose 100-200 mg/dl until acid/base status
Monitoring:
1) Glucose and VS q 1 hr, SMA-10 q 2hr
2) Calculate and plot anion gap (Na + K Cl – HCO3), uncorrected sodium and corrected sodium at bedside. (Corrected Na: add 1.5 mEq Na for each 10 mg/dL of glucose above 100). It is an excellent estimate of the mM of ketonemia
3) Ca, Phos- 8 hrs after initiation of fluids
4) Dip all urine
5) Strict I/Os
Dispostion: (notify endocrine/diabetes of disposition or for questions pertaining to the above protocol.)
1) admit to PICU if insulin infusion required.
2) admit to floor if to be managed by diet and sub Q insulin
Insulin
|
|
Onset
|
Peak
|
Therapeutic (hrs)
|
Phrmacologic (hrs
|
|
Lispro-H(humalog)
|
0-10 min
|
30-60 min
|
2
|
2-4
|
|
Regular
|
1/2- 1 hr
|
2-4hrs
|
6-8
|
5-12
|
|
NPH(intermediate acting)
|
1-4 hrs
|
8 hrs
|
10-16 hrs
|
16-24 hrs
|
Start w/ mixed splt insulin doses of subQ-lispro(H) and NP.
New patient guidelines
|
|
AM/PM distribution
|
AM
|
|
PM
|
|
Age (yrs)
|
Dose of insulin (U/kg)
|
AM
|
PM
|
H
|
NPH
|
H
|
NPH
|
|
>7
|
0.7
|
2/3
|
1/3
|
1/3
|
2/3
|
½
|
½
|
|
3-7
|
0.5
|
2/3
|
1/3
|
1/3
|
2/3
|
½
|
½
|
|
<3
|
0.4
|
2/3
|
1/3
|
0
|
All
|
O
|
All
|
Alternative method:
|
Age (yrs)
|
AM humalog
|
AM NPH
|
PM humalog
|
PMNPH
|
|
³7
|
Wt in Kg / 6
|
2x AM humalog
|
AM humalog / 2
|
AM humalog / 2
|
|
<7
to
³3
|
Wt in Kg / 8
|
2x AM humalog
|
AM humalog / 2
|
AM humalog / 2
|
|
<
3
|
0
|
Wt in Kg / 3
|
0
|
AM NPH / 2
|
In known diabetic / established patient:
Start w/ usual home regimen, recognizing that the usual outpatient insulin dose may not be adequate for glycemic control immediately following successful management of DKA. Dose requirements typically increase also during puberty due to increased caloric intake and elevated sex steroids/ GH levels.
Write for the following slide scale to add or subtract uits of humalog at times of the AM and PM dosing of insulin (to be used only at the breakfast and supper insulin administration times):
|
Glucose
|
>
7 yrs old
|
3-7 yrs old
|
< 3yrs old
|
|
<
50 (mg/dL)
|
-2
|
-1
|
** see below
|
|
50-79
|
-1
|
-1/2
|
*
|
|
80-120
|
0
|
0
|
*
|
|
121-180
|
+1
|
+1/2
|
*
|
|
181-240
|
+2
|
+1
|
*
|
|
>240
|
+3
|
+1 1/2
|
*
|
**notify the endocrine service if the young child has a blood glucose > 240 and moderate or large ketones in the urine. If the young child has a glucose < 80 at these specific times (breakfast, dinner), treat patient w/ 5-10 g of oral carbohydrate. If the hypoglycemia does not respond, notify the endocrine service. At other times, hypoglycemia should be treated w/ 15 g of glucose assuming that patient is able to take oral fluids safety.
Blood sugar testing:
Should be done before each meal, bedtime, snack and at 2a.m. This testing pattern gives an overall picture of insulin action throughout the day.
