DIABETIC KETOACIDOSIS PROTCOL

PAEDIATRIC INTENSIVE CARE – CLINCIAL PRACTICE GUIDELINE

DIABETIC KETOACIDOSIS PROTOCOL

(Call consultant on admission)

1. Introduction

DKA is a potentially life-threatening medical emergency due to absolute or relative insulin deficiency

coupled with counter-regulatory hormones excess.

2. Aim

To provide a guideline for management of the patient presenting with DKA.

The objective of this guideline is to:

• Recognise DKA early

• Correct metabolic disturbances (dehydration, ketoacidosis, hyperglycemia)

• Prevent complications

• Identify and treat precipitating events

3. Parameters of the guideline:

These guidelines are intended for the management of children who present with DKA

4. Definition:

A. DKA: Diabetes Ketoacidosis

Clinical & Biochemical Criteria

Clinical history

Clinical signs

Biochemical

Polyuria, polydipsia,

polyphagia, wt loss or

abdominal pain

or vomiting

Varying degree of dehydration,

Kussmaul respiration,

fruity (acetone) smell,

altered sensorium

RBS >11mmol/1,

Venous Blood Gas (pH <7.3mmHg,

HCO

3

<15 mmol/l), ketonemia or

ketonuria and glycosuria

B. CBG – Capillary Blood Glucose

6. Emergency Management:

A. Resuscitation

Airway: If comatose, insert airways & NG tube

Breathing: Give oxygen via face mask (even if O2 Sat > 95% in RA)

Circulation: Insert IV cannula + IA line & take blood samples (see below)

Cardiac monitor (ECG for hypo/hyperkalemia)

+ IDC

If in shock, give 10ml/kg normal saline bolus ½-1hr, maximum of 30mls/kg to restore

circulation. (N.B. Discuss with the Consultant if the patient has received 30mls/kg)

Algorithm for the management of diabetic ketoacidosis. Source: adapted from Dunger et al. Karger Publ. 1999

Immediate assessment

Shocked (reduced peripheral pulses) Dehydration >5% Minimal

dehydration

Reduced conscious level/coma Not in shock Tolerating oral

fluids Acidotic (hyperventilation)

Vomiting

Acidosis not improved Blood glucose 17mmol/l Neurological deterioration

Or Warning signs:

Blood glucose falls >5mmol/l/h headache,

slowing heart rate, irritability,

decreased conscious level

Incontinence, specific

neurological

signs

Improvement

Clinically well, tolerating oral fluids

B. Initial investigation

• Blood glucose (formal sugar & CBG)

• Urea & electrolytes (electrolytes from blood gases can be used)

• Blood gases (venous give very similar pH & CO

2

to arterial)

Clinical History

Polyuria

Polydipsia

Wt loss (Weigh)

Abdominal pain Weakness

Vomiting

Confusion

Clinical Signs

Assess dehydration

Deep sighing respiration (Kussmaul)

Smell of ketones

Lethargy/drowsy +/- vomiting

Biochemical features & investigation

Ketones in urine

Elevated blood glucose

Acidaemia

Blood gases urea, electrolytes Others

investigations as indicated

Diagnosis confirmed

Diabetic Ketoacidosis

Call senior staff/Consultant.

Resuscitation

Airway + NG tube

Breathing (100% O

2

)

Circulation (0.9% saline 10-20

ml/kg over 1-2h & repeat until

circulation is restored) but do

not exceed 30ml/kg

IV Therapy

Calculates fluid requirement

Correct over 48 hrs

Saline 0.9%

ECG for T wave changes

Add KCL 40mmol per litre fluid

Therapy

Start with SC insulin. Continue

oral fluids

Continuous insulin infusion

0.1ml/kg/hr

Clinical observations

Hourly blood glucose

Hourly fluids input & output

Neurological status at least hourly

Electrolytes at least 2 hourly after start of IV therapy

Monitor ECG for T-wave changes

IVF Therapy

Change to 0.45% saline + 5% glucose

Adjust sodium infusion to promote an increase

in measured serum sodium

Re-evaluate

IV fluid calculations

Insulin delivery system & dose

need for additional resuscitation

Consider sepsis

Exclude hypoglycemia

Is it cerebral edema?

Management

Give mannitol 0.5-1g/kg , Restrict IV fluids by 1/3 , Call

senior staff

Move to ICU, Consider cranial imaging only after

patient is stable

Transition to SC insulin

Start SC insulin then stop IV insulin after 30 minutes

No improvement

• HbA1c

• Urine ketones and glucose (N.B. Blood ketones is more superior to urine ketones)

• Islet cell antibodies, insulin antibodies, GAD antibodies, antiendomyseal lgA antibodies

and TFTs for all newly diagnosed patients.

• Other investigations only if indicated; FBC, Urinalysis, Chest X-Ray and Cultures

(blood, urine, throat, CSF) then give appropriate antibiotics

(N.B. leukocytosis is common in DKA and does not necessarily indicates sepsis, unless there is fever)

9. Management

A. Fluids

• Treat shock with bolus 10mls/kg 0.9% saline over 1/2-1hr, (max. of 30mls/kg), (if further

fluid boluses required at this stage, discuss with consultant

)

• After restoration of BP, all children with DKA and unequivocal signs of dehydration

should be given the following amount of IVF (based on maintenance

requirements of 80% of normal, and 3-5% of dehydration corrected over 48hrs)

irrespective of their apparent degree of dehydration (see table below):

Wt (kg)

5

6

7

8

9

10

12

14

16

18

20

25

30

35

40

45

(ml/hr)

24

28

32

36

40

45

50

55

65

70

75

80

90

95

105

110

(N.B. this fluid rate (ml/hr) includes deficit AND maintenance fluid needs)

• Fluid therapy should be reviewed if oliguria develops due to tubular necrosis caused by

severe hypotension before resuscitation may require fluid restriction. But persistent

hypovolemia may require extra fluids

• Initial fluids should be 0.9% saline or Lactated Ringers with 40mmol KCL in 1 L for the

1

st

48 hrs (see section on Potassium).

• Change IVF to 5% dextrose (add 100mls of D50% in 900mls 0.9 N/S), you can increase

the dextrose concentration to as high as 12.5% (discuss with consultant)

1

• Indications of adding glucose in the maintenance fluids:

 Serum glucose is 14 mmol/l

 Rapid drop in blood glucose level (>5-8 mmol/l per hr) even if the serum

glucose is >14 mmol/l

 Ketacidosis remains despite correction of hyperglycemia

• Give 2-5ml/kg D10% bolus if CBG 3-4mmol/l

• Do not change the IVF to 0.45% saline if the corrected Na level does not rise

1

• Start oral fluids when clinically improved. (N.B these oral fluids should be subtracted from IVF if

still within 48 hrs)

B. Insulin

• No initial insulin bolus

• Start insulin after 1 hr of initial IVF

• Add 50 units insulin “short acting” (regular) to 49.5mls of 0.9% saline to make 1units/ml

solution. Prime giving set prior to commencing infusion

• Run at 0.1unit/kg/hr, (N.B. in <5yrs and neonates start with 0.05unit/kg/hr).

• Correct ketoacidosis first before hyperglycemia.

• Do not reduce or stop insulin infusion, instead add glucose in the IVF (see Fluids

• )

• Blood glucose fall rate should be 3-5 mmol/l per hour

• Keep blood glucose at 8-12mmol/l

• The best time to change insulin infusion to SC is just before a meal, when the child is alert

and metabolically stable (glucose 8-12mmol/l, pH >7.3 & HCO3 >15). The insulin

infusion should only be stopped 30mins after the 1

st

SC insulin injection.

C. Potassium

• Start KCl at a concentration of 40-60mmol/l (40mmol if Body Wt <30kg, and 60mmol if

>30kg)

• Extreme care should be taken if the initial serum K is >5.5mmol/l or if the patient is

anuric. Check ECG monitor for peak T wavesECG monitor( Discuss with Consultant)

D. Bicarbonate

• Discuss with the Consultant.

E Monitoring & Observation

Hourly blood glucose

Hourly fluid input and output

Neurological status at least hourly

Electrolytes and blood gases 2 - 4hourly after start of IV therapy

BP, PR, RR 1-2 hourly & Temperature 4 hourly.

Urine ketones and glucose 4 hourly or every voids

Monitor ECG for T- wave changes

F. Complications of therapy

• Hypoglycemia

• Hypokalemia

• Aspiration pneumonia

• Cerebral oedema

10. Cerebral edema

• If suspected, exclude hypoglycemia and inform Consultant immediately.

• Treatment:

1. Keep NBM, give 100% O

2

, and elevate the head of the bed by 30º

2. Reduce the rate of IVF to 2/3 of the calculated IVF

3. Give mannitol 0.5-1g/kg IV over 20 mins, may repeat if no initial response in 30

mins to 2hrs.

4. Hypertonic saline (2.7-3%) 5-10 ml/kg over 30mins may be an alternative or a

second line of therapy if no initial response to mannitol

5. Intubation and mechanical ventilation for impending repiratory failure, avoid

aggressive hyperventilation (keep PCO

2

at 30-35 mmHg)

11. Transition from Insulin infusion to Subcutaneous:

Step1. Determine the Total daily Insulin Requirement using a Sliding Scale

• Subcutaneous insulin therapy is initiated with regular (short acting) insulin given in a

dose of 0.2U/kg/dose, with the subsequent dose being adjusted every 6 h, depending

on the response as judged by the blood glucose levels and ketonuria

• Monitor CBG 4 times/day (pre-meals & after midnight)

• Use Table Appendix 2 Column 1, 2 & 5 for calculating and adjusting a sliding

scale

Step 2. Use Twice Daily Insulin Regimen

• Divide the Total daily Insulin Requirement into (2/3 before breakfast, 1/3 before

dinner)

Step 3. Determine components of each dose

• 2/3 of each dose as intermediate-acting (Isophane) insulin.

• 1/3 as short-acting (Regular)

• If using mixtard insulin, give 2/3 dose in the morning and 1/3 in the afternoon

NOTE:

• CBG can still be fluctuating even after a fixed insulin-meal regimens as calculated

above

• First exclude inter-current illness or stress etc.

• Use “10% rule” for insulin dose changes after determining the time at which

abnormal CBG occurs.

• Modify insulin doses by 10 %, e.g. if CBG is persistently out of range before dinner

then the dose modification applies only to the morning or lunch time insulin and

the amount is determined by 10% of the morning dose.

Appendix 1

• Anion gap: (12 + 2mmol/l): (Na + K) – (Cl + HCO3).

• Osmolality: (280 – 300mmol/l): 2(Na + K) + Glucose(mmol/l) + Urea

• Corrected Na: measured Na + [2(plasma glucose (mmol/l) – 5.6)] ÷ 5.6 to calculate the

corrected Na use this link Tools\correctedNA.pdf

• Fluid calculation, use this link for calculating fluid rates;

http://www.bsped.org.uk/professional/guidelines /docs/DKACalculator.pdf

Appendix 2

TABLE1: Subcutaneous Insulin Dosing

BOLUS INSULIN

AGE

(YR)

TARGET

GLUCOSE

(MMOL/L)

TOTAL

DAILY

INSULIN

(U/KG/D)

*

BASAL

INSULIN, % OF

TOTAL DAILY

DOSE

Units Added per

5.5mmol/l above

Target

0–5

5.5-11.1

0.6–0.7

25–30

0.50

5–12

4.4-8.3

0.7–1.0

40–50

0.75

12–18

4.4-8.3

1.0–1.2

40–50

1.0–2.0

[‡]

*

Newly diagnosed children in the “honeymoon” may only need 60–70% of a full replacement dose.

Total daily dose per kg increases with puberty.

‡

For finer control, extra insulin may be added in 2.8mmol/l increments.

TABLE2: A 6 Hourly Sliding Scale for SC insulin

Age

(yrs)

Insulin

SC

CBG (mmol/l)

5-10

10-15

15-20

>20

0-5

Insulin

0.15U/kg/dose

0.15U/kg/dose +

0.5Unit

0.15U/kg/dose +

1Unit

GO BACK

TO INSULIN

INFUSION

5-12

Insulin

0.2U/kg/dose

0.2U/kg/dose +

0.75Unit

0.2U/kg/dose +

1.5Units

12-18

Insulin

0.25U/kg/dose

0.25U/kg/dose +

1Unit

0.25U/kg/dose +

2Units

(N.B. The above Sliding scale table is derived from Table 1)

Appendix 3: Diagnostic criteria for Cerebral Edema in children with DKA

1. Diagnostic criteria for cerebral edema

• Abnormal motor or verbal response to pain

• Decorticate or decerebrate posture

• Cranial nerve palsy (especially lll, l V and Vl)

• Abnormal neurogenic respiratory pattern (e.g. grunting,

Cheyne-Stroke respiration, apneoa)

2. Major criteria

• Altered mentation/fluctuating level of

consciousness

• Sustained heart rate deceleration (decrease

of >20 beats/min) not attributing to

improved intravascular volume or sleep

state.

• Age-inappropriate incontinence

3. Minor criteria

• Vomiting

• Headache

• Lethargy or not easily arousable

• Diastolic BP >90mmHg

• Age <5 years

________________________________________________________________________________________________

To diagnose Cerebral Edema, the following criteria has to be met: (N.B. These criteria has 92%

sensitity & 4% false positive rate)

 1 diagnostic criterion OR

 2 major criteria OR

 1 major and 2 minor criteria.

References:

1. Wolfdorf J, Graig ME, Daneman D, et al. Diabetic Ketoacidosis in Children and Adolescents

with diabetes. (ISPED Clinical Practice Consensus Guidelines 2009 Compendium). Pediatric

Diabetes 2009: 10 (Suppl. 12): 118-133

2. Edge JA. BSPED Recommended DKA Guidelines 2009, November 2009

3. Jeha GS, Haymond MW. Clinical Features and diagnosis of Diabetic Ketoacidosis in Children.

2010 UpToDate.

4. Jeha GS, Haymond MW. Treatment and Complications of ketoacidosis in Children. 2010

UpToDate.

5. Jeha GS, Haymond MW. Cerebral Edema in Children with Diabetic Ketoacidosis. 2010

UpToDate.

6. Ismail HM, Phak NG, Thomas T. Paediatric Protocols for Malaysian Hospitals. 2

nd

Edition,

2008. Kementerian Kesihatan Malaysia.

7. Sperling MA. Type 1 Diabetes Etiology and Treatment. Humana Press Inc. 2003. New Jersey.

8. Behrman RE, Kliegman RM, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics. 18

th

Edition, 2007. Saunders, Philadelphia.

9. Fogel N, Zimmerman D. Management of Diabetic Ketoacidosis in the Emergency Department.

2009: 10(4): 246-251 (not yet published)

10. Clinical Practice Guidelines – Diabetic Ketoacidosis, 2006-2009. The Royal Children’s

Hospital, Melbourne Australia.

11. Dunger DB et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric

Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children and

Adolescents. Paediatrics 2004: 113; e133-e140.

12. Jones KM, Molyneux E, Philips B, Wieteslka S. Advanced Paediatric Life Support, The

Practical Approach. 4

th

Edition, 2005. Blackwell Publishing Ltd, Massachusetts, USA.

13. Shann F. Paediatric Intensive Care Guideline, 3

rd

Edition, 2008. Royal Children’s Hospital,

Melbourne, Australia

14. Lifshitz F. Pediatric Endocrinology. Vol. 1, Obesity, Diabetes Mellitus, Insulin Resistance, and

Hypoglycemia. 5

th

Edition, 2007. Informa Healthcare, New York, USA.

15. http://www.bsped.org.uk/professional/guidelines/

Scope and Application

This CPG is intended for use by all health care

workers in their daily care of paediatric patients

Effective Date

2010

Supercedes Policy Number Not applicable

Review Responsibilities

The Chairperson of the Paediatric CSN will

initiate the review of this guidelines every 3 years

from the date of issue or as required.

Further Information

Paediatric CSN Chairperson

RESPONSIBILITY:

CPG Owner: National Paediatric CSN

CPG Writer: Ministry of Health Date: 2010

Endorsed:

National Medicines & Therapeutic Committee, MOH

Date: 23 November 2010

Endorsed:

National Health Executive Committee, MOH

Date: 25 November 2010