When Kids Are Sweet as Sugar and

Sick as *&#!

Teri Campbell RN, BSN, CEN, CFRNUniversity of Chicago Aeromedical NetworkAerocare

DKA

• Complex metabolic state• Emergency vs. life-threatening• Hospitalizations• Cerebral edema

Objectives

• Participants will define DKA• Participants will identify precipitating factors• Participants will discuss common presentation• Participants will review pre-hospital vs. hospital stabilization goals• Participants will discuss treatment options• Participants will review potential complications

Definition

Triad

• Hyperglycemia• Ketonemia• Acidemia

That’s a lot of “emias”…

Definition

• Blood glucose: > 250 mg/dl• PH: < 7.3• Serum Bicarbonate: < 15 mEq/L• Urinary ketone: > = 3+• Serum Ketone: positive at 1:2 dilutions• Serum osmolality: Variable

All the stats…

• Incidence / frequency

• Race

• Mortality

Precipitating factors

• New diagnosis• Infections• Non-compliance• Endocrine changes• Caregiver lack of compliance• Pump failure

What a story…

History• Polydipsia, Polyuria

• Fatigue• Malaise• N / V• Weight loss• Fever

History

Abdominal pain

Pathology

Increase of “stress hormones”• catecholamines• glucagon• growth hormone• cortisol

Decreased Insulin

Pathology

Lots and lots of sugar to no avail…

• Proteolysis• Ketones• Lipolysis• Lactic acids

Presentation

Soooo… How do they LOOK?

• mental status changes• tachycardia• kussmaul • B/P• delayed cap refill• possibly febrile

Hyperglycemia

• High serum glucose

• Big sponge

Dehydration and thirst

• Intra-cellular dehydration• Extra-cellular fluid expansion• Hyponatremia• Polyuria• H20 losses exceed NaCl losses• Decrease urine blood flow• Glucose retention

Acidosis

2 main culprits

Ketones : Proteolysis

Lactic acid: Lipolysis Tissue hypoperfusion

Hyperosmolality

• Directly related to hyperglycemia• Increased serum osmols• Increased cerebral osmols

Electrolyte disturbances

• NA: low, normal or high

• Increased K+

• Decreased K+

Treat hypokalemia first or…ZAP!

Fluids → K+ → Insulin

Labs

• Glucose

• K+

• ABG’s

• Electrolytes: CL, HCo3, BUN, Cr, Phos

Labs

• CBC• blood / urine culture• UA• serum osmolality• EKG: hyperK+ = peaked T waves

SHOCK hyperkalemia? _______

Pre-hospital

• A: mental status changes

• B: O2, BVM, Sellicks

• C: Isotonic fluids• 20 cc/kg X ONE…• What size IV?

Pre-hospital

• D: Altered mentation?

• History?

Long transport?

It’s time we face reality, my friends

Global goals

• Restore perfusion

• Give insulin

• Correct electrolyte disturbances

• Avoid complications

Where are we going?

And why am I in this Hand basket?

Fluid therapy

• 1st 1-2 hours of therapy• Isotonic 20cc/kg• Shock• 0.9 NS vs. 0.45 NS• 1.5 – 2.0 X maintenance• BSA: 1200cc/M2/day

Fluid therapy

• 4-2-1 Rule

• 1st 10 kg : 40 cc

• 2nd 10 kg : 20 cc

• 1cc for every kg over (20kg)

37 kg child: 1st 10 kg: 40cc 2nd 10 kg: 20 cc all the other kg (1cc/kg): 17 cc 77 cc/hr

Potassium supplement

• Profound hypoK+: oral vs. IV• Treat before insulin• K+ > 5.5: No K+ to IVFs• KCL vs K phosphate

Slowwwww lab?

Insulin

• Bolus controversy• timing controversy• prime the tubing• 0.1 units/kg/hr• 0.05 units/kg/hr• clear ketones• Regular insulin 1:1

Bicarbonate

• Rarely indicated• Evidence?• PH < 7.0• Adverse hemodynamic effects

• Hypokalemia, hyperNA, alkalemia• Never give IV push

Glucose

• Blood sugar @ 250 mg/dL• D5, D10 • Ketones, prevent hypoglycemia• serum glucose: 100-150 mg/dL

150-250 mg/dL• Fall: 50-70 mg/dL / first hour

Serum Osmolality

• Normal range• > 320 risk for cerebral edema• > 320 correct volume over 36 hours• > 340 correct volume over 48 hours

Complications

Cerebral edema

• More common kids / adol.• Incidence: 0.3-1.0%• Mortality: 70%• Risk factors• Presentation

Pathology

• Hyperglycemia = high serum osmols• High serum osmols = high brain osmols• Rapid correction: volume or sugar• Gradient: intracerebral & serum osmols• Free H20 into brain

Treatment

Initial CT

Mannitol

Hypertonicsaline

ARDS

• Rare

• Potentially fatal

• Lots of crystalloids

• Normal cardiac function

Key points

• Often misdiagnosed

• Replace cellular and intravascular losses

• Insulin to allow glucose utilization

• Possible correction of electrolytes

• Prevent complication

In conclusion…

Keep it slow…..

It took them weeks to get here…

It will take days to fix them….

When Kids Are Sweet as Sugar and

Sick as *&#!

Teri Campbell RN, BSN, CEN, CFRNUniversity of Chicago Aeromedical NetworkAerocare

tlcsoup@aol.com