Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk Children s Acute Transprt Service Clinical Guidelines Diabetic Ketacidsis Dcument Cntrl Infrmatin Authr M Clement E Randle Authr Psitin ANP Cnsultant Dcument Owner E. Plke Dcument Owner Psitin Service Crdinatr Dcument Versin Versin 3 Replaces Versin January 2016 First Intrduced Review Schedule 2 Yearly Active Date January 2018 Next Review January 2020 CATS Dcument Number Applicable t All CATS emplyees Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 1 f 6
Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk 1. Assessment Diagnsis requires a cmbinatin f hyperglycaemia, acidsis & ketsis. If all three features are nt present then an alternative diagnsis shuld be cnsidered such as: Lactic acidsis, inbrn errr f metablism, alchlic ketacidsis, salicylate pisning r sepsis. 1.1 Histry Plyuria Plydipsia Usual insulin regimen (if knwn diabetes) Any triggers (eg. Infectins, stress) 1.2 Clinical Acidtic breathing pattern Abdminal pain / vmiting Level f cnsciusness Assess the GCS Institute hurly neurlgical bservatins whether drwsy n admissin r nt Assess & recrd level f dehydratin s that cmparisn can be made by thers later. Mild/Mderate 5% ph >7.1 dry mucus membranes, reduced skin turgr. Severe, 10% ph <7.1 as abve + sunken eyes. SHOCKED Rapid thready pulse +/- hyptensin. D nt use capillary refill time alne as an indicatr f shck (hypcarbia will cause prlnged capillary refill). D nt rutinely give a fluid blus t children and yung peple nly if signs f shck. Give a maximum f 10ml/kg blus befre discussing with senir dctr. Give an abslute maximum f 30mls/kg. Over estimatin f degree f dehydratin is dangerus. Mst imprve with administratin f insulin. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 2 f 6
Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk 1.3 Examinatin Lk particularly fr evidence f Infectin Ileus Cerebral edema Headache / Irritability Reduced level f cnsciusness Bradycardia & hypertensin Cerebral edema is the mst cmmn cause f mrtality. Risk factrs fr cerebral edema include Severe hypcapnea at presentatin (<2kPa) Yunger age First presentatin Elevated serum urea at presentatin Bicarbnate administratin Rapid fall in crrected sdium (see belw) If suspected discuss with CATS immediately and give: Mannitl 20% 0.5g/kg (2.5mls/kg) ver 10 15 mins OR Hypertnic Saline 2.7% 3mls/kg ver 10 15 mins Half maintenance fluid rates and discuss with senir medical supprt r CATS The aim is t slwly crrect metablic abnrmalities 1.4 Indicatins fr discussin with CATS ph <7.1 with marked hyperventilatin Severe dehydratin with shck Depressed level f cnsciusness Headache Age <2yrs. 2. Resuscitatin 2.1 Airway & Breathing Ensure airway patency Intubatin is rarely necessary. Hyperventilatin is a nrmal cmpensatry mechanism fr metablic acidsis Give 100% xygen via face mask Insert NGT (if decreased cnscius level r recurrent vmiting), and leave n free drainage Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 3 f 6
Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk 2.2 Circulatin Insert 2 IV cannulae Take bld samples Bld glucse U&Es (can use electrlytes n bld gas until available) Bld gas (venus gives similar values t arterial) Bld ketnes if pssible (superir t urine ketnes) FBC / BC if sepsis suspected Ensure full cardiac mnitring (lk fr peaked T waves with hyperkalaemia) D nt use capillary refill as an indicatr fr fluid blus administratin Hypcarbia causes peripheral vascnstrictin Only if shcked (tachycardic, pr peripheral pulses +/- hyptensin) give 10mls/kg 0.9% saline as a blus. Assess effect carefully, discuss with senir dctr if cnsidering further fluid blus - abslute maximum 30ml/kg ttal blus. Over estimatin f dehydratin is dangerus. D nt give bicarbnate. 3. Management 3.1 Insulin There is sme evidence that cerebral edema is assciated with early insulin administratin. Start sluble insulin at 0.05-0.1 units/kg/hr 1 hur after starting IV fluids. Aim t reduce the bld glucse n faster than 5mmls/hr. Once bld glucse <14mml/l add 5% glucse t IV fluids. If bld glucse falls t <4mml/l give 2mls/kg 10% glucse & increase glucse cntent f IV fluids t 10%. Insulin infusin rate can be temprarily reduced (fr 1hr) but shuld be cntinued at 0.05-0.1 units/kg/hr t switch ff ketgenesis. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 4 f 6
Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk 3.2 Fluids Requirement = (Maintenance + Deficit (replace ver 48hrs)) any blus fluid given ver the first 20ml/kg Maintenance requirements (reduced in the August 2015 BSPED guidance) Weight (kg) Rate (ml/kg/ 24hrs) <10 kg 2ml/kg/hur 10-40 kg 1ml/kg/hur >40kg 40ml per hur Nenates may require larger vlumes. Deficit (ml) = % dehydratin x bdy weight (kg) x 10 Hurly rate = 48 hr maintenance + deficit resuscitatin fluids given ver the first 20ml/kg 48 Examples 6yr child weighing 20kg, assessed as mderate DKA with ph 7.15, therefre 5% dehydratin wh received n saline bluses fr resuscitatin. Deficit 5% x 20 kg x10 Divide ver 48 hurs Add maintenance at 1ml/kg/hr Ttal = 1000ml = 21ml/hr = 20ml/hr = 41ml/hr 16 yr child 60kg, assessed as severe DKA, ph 6.9, therefre 10% dehydratin with circulatry cllapse and received 30ml/kg 0.9% sdium chlride bluses. Deficit 10% x 60kg x 10 Subtract resus fluid ver 20ml/kg (10ml/kg) Divide ver 48 hurs Add maintenance at 40ml/hr Ttal = 6000 ml = -600ml = 112.5 ml/hr = 40 ml/hr = 152.5 ml/hr 3.3 Type f fluid 0.9% saline + 20mml KCL per 500ml (nce urine utput cnfirmed). Once bld glucse is < 14mml/l change t glucse cntaining fluid. Calculated deficit replacement fluid must be cmpleted - if tlerating ral fluids, ensure IV rehydratin rate is reduced accrdingly t accunt fr ral intake. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 5 f 6
Printed cpies f this dcument may nt be up t date, btain the mst recent versin frm www.cats.nhs.uk 4. Observatins Strict fluid balance (catheterise yunger patients r thse with lw GCS) Hurly capillary bld glucse measurement Hurly BP, HR Cntinuus ECG mnitring Half hurly (r mre frequently) neurlgical assessment 1-2 hurly capillary bld ketnes 2 4 hurly capillary bld gas & U&Es Twice daily weights 5. Trubleshting 5.1 Acidsis: If acidsis is nt crrecting, cnsider: Inadequate fluid resuscitatin Insufficient insulin t switch ff ketgenesis Hyperchlraemic acidsis If Cl is >80% f Na Base excess due t Cl = Na - Cl - 32 5.2 Crrected Sdium: Use crrected sdium t assess adequacy f rehydratin. Crrected Na = Measured Na + 0.4 x (serum glucse mml/l 5.5) If Crrected Na RISING >5mml/l in 4hr indicates t much fluid LOSS Increase fluid rate by 25% If crrected Na FALLING >5mml/l in 4hr indicates t much fluid GAIN Decrease fluid rate by 25% 6. Indicatin fr intubatin Ventilatry failure Lss f airway Decmpensated shck Intubatin & ventilatin pses a significant risk with wrsening acidsis due an abrupt rise in pco 2 - Aim t match pre intubatin pc02 and allw t rise slwly. References British Sciety fr Paediatric Endcrinlgy and Diabetes. Recmmended DKA guidelines 2015, Julie A Edge. NICE guidelines. Diabetes in children and yung peple: diagnsis and management f type 1 and type 2 diabetes in children and yung peple. Nvember 2016. Children s Acute Transprt Service prvides paediatric intensive care retrieval fr Great Ormnd Street, The Ryal Brmptn and St Mary s NHS Trusts. Funded and accuntable t the Nrth Thames Paediatric Intensive Care Cmmissining Grup thrugh Great Ormnd Street NHS Trust. Page 6 f 6