Emergency care part 1 managing diabetic ketoacidosis dka
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Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA). Slide no 2. Programme. Managing DKA. 1. 2. Treating and preventing hypoglycaemia. 3. Surgery in children with diabetes. Diabetic Ketoacidosis. Occurs when there is insufficient insulin action Commonly seen at diagnosis

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Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)

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Emergency care part 1 managing diabetic ketoacidosis dka

Emergency CarePart 1: Managing Diabetic Ketoacidosis (DKA)

Presentation title


Presentation title

Slide no 2

Programme

Managing DKA

1

2

Treating and preventing hypoglycaemia

3

Surgery in children with diabetes


Diabetic ketoacidosis

Diabetic Ketoacidosis

Occurs when there is insufficient insulin action

Commonly seen at diagnosis

Is a life-threatening event

Child should be transferred as soon as possible to the best available site of care with diabetes experience Initiate care at diagnosis

Slide no 3


Type 1 diabetes

Type 1 Diabetes

Increased urine

Dehydration

Thirst


Presentation title

DKA

  • Weight loss

  • Ketones

    • Nausea

    • Vomiting

    • Abdominal pain

    • Altered level of consciousness

  • Shock

  • Dehydration

Liver

Muscle

Fat

Ketones

Weight loss


Clinical features

Clinical features

Slide no 6


Managing dka

Managing DKA

  • Refer to best available site of care whenever possible

  • Need:

    • Appropriate nursing expertise (preferably a high level of care)

    • Laboratory support

    • Clinical expertise in management of DKA

  • Written guidelines should be available

  • Document and use the form

Slide no 7


Dka monitoring form

DKA monitoring form


Dka monitoring

DKA monitoring

  • DKA protocol available to the clinic


Principles of dka management 1

Principles of DKA management (1)

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 10


Principles of dka management 2

Principles of DKA Management (2)

  • Correction of shock or decreased peripheral circulation – quick phase

  • Correction of dehydration - slow phase

    Do not start insulin until the child has been adequately resuscitated, i.e. good perfusion and good circulation

Slide no 11


Principles

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 12


Assessment

Assessment

  • History and examination including:

    • Severity of dehydration. If uncertain about this, assume 10% dehydration in significant DKA

    • Level of consciousness

  • Determine weight

  • Determine glucose and ketones

  • Laboratory tests: blood glucose, urea and electrolytes, haemoglobin, white cell count, HbA1c

Slide no 13


Resuscitation 1

Resuscitation (1)

Ensure appropriate life support (Airway, Breathing, Circulation, etc.)

Give oxygen to children with impaired circulation and/or shock

Set up a large IV cannula/intra-osseous access.

Give fluid (saline or Ringers Lactate) at 10ml/kg over 30 minutes if in shock, otherwise over 60 min. Repeat boluses of 10 ml/kg until perfusion improves

Slide no 14


Resuscitation 2

Resuscitation (2)

If no IV available, insert nasogastric tube or set up intraosseous or clysis infusion

Give fluid at 10 ml/kg/hour until perfusion improves, then 5 ml/kg/hour

Use normal saline, half-strength Darrows solution with dextrose, or oral rehydration solution

Decrease rate if child has repeated vomiting

Transfer to appropriate level of care

Slide no 15


Principles1

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 16


Rehydration 1

Rehydration (1)

Rehydrate with normal saline

Provide maintenance and replace a 10% deficit over 48 hours

Do not add urine output to the replacement volume

Reassess clinical hydration regularly.

Once the blood glucose is <15 mmol/l, add dextrose to the saline (add 100 ml 50% dextrose to every litre of saline, or use 5% dextrose saline)

Slide no 17


Rehydration 2

Rehydration (2)

If IV/intra-osseous access is not available:

  • Rehydrate orally with oral rehydration solution (ORS)

  • Use nasogastric tube at a constant rate over 48 hours

  • If a NG tube tube is not available, give ORS by oral sips at a rate of 1 ml/kg every 5 min if decreased peripheral circulation, otherwise every 10 min.

  • Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible

Slide no 18


Principles2

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 19


Insulin therapy 1

Insulin therapy (1)

Start insulin after your ABCs (treat shock, start fluids) - stability has improved

Insulin infusion of any short acting insulin at 0.1U/kg/hour (0.05 U/kg/hr if younger than 5 years)

Rate controlled with the best available technology (infusion pump)

Do not correct glucose too rapidly. Aim for decrease of 5 mmol/l per hour

Slide no 20


Insulin therapy 2

Insulin therapy (2)

  • Example:

    • A 24 kg child will need 2.4 U/hour

    • Put 24 U short acting insulin into 100 ml saline and run at 10 ml/hour

    • Equivalent to 0.1 U/kg/hour

    • Younger children: lower rate e.g. 0.05 U/kg/hour

Slide no 21


Insulin therapy 3

Insulin therapy (3)

  • If no suitable control of the rate of the insulin infusion is available

    OR

  • No IV access use sub-cutaneous or intra-muscular insulin.

  • Give 0.1 U/kg of short-acting regular or analogue insulin subcutaneously or IM into the upper arm

  • Arrange transfer of the child to a facility with resources to establish intravenous access as soon as possible

Slide no 22


Principles3

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 23


Electrolyte deficits

Electrolyte deficits

The most important is potassium

Every child in DKA needs potassium replacement

Other electrolytes can only be assessed with a laboratory test

Obtain a blood sample for determination of electrolytes at diagnosis of DKA

Slide no 24


Ecg and potassium levels

ECG and Potassium Levels


Potassium 1

Potassium (1)

Levels determined by laboratory test

If not available, can use ECG (T waves)

Start potassium replacement once serum value known or patient passes urine

If no lab value or urine output within 4 hours of starting insulin, start potassium replacement

Slide no 26


Potassium 2

Potassium (2)

Add KCl to IV fluids at a concentration of 40 mmol/l (20 ml of 15% KCl has 40 mmol/l of potassium)

If IV potassium not available, replace by giving the child fruit juice or bananas.

If rehydrating with oral rehydration solution (ORS), no added potassium is needed

Slide no 27


Potassium 3

Potassium (3)

Monitor serum potassium 6-hourly, or as often as is possible

In sites where potassium cannot be measured, consider transfer of the child to a facility with resources to monitor potassium and electrolytes

Slide no 28


Principles4

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 29


Acidosis

Acidosis

Usually due to ketones

Poor circulation will make it worse

Correction not recommended unless the acidosis is very profound

If bicarbonate is considered necessary, cautiously give 1-2 mmol/kg over 60 minutes. Usually not needed

Slide no 30


Principles5

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 31


Infection

Infection

Infection can precipitate the development of DKA

Often difficult to exclude infection in DKA, as the white cell count is often elevated because of stress

If infection is suspected, treat with broad-spectrum antibiotics

Slide no 32


Principles6

Principles

Correction of shock

Correction of dehydration

Correction of hyperglycaemia

Correction of deficits in electrolytes

Correction of acidosis

Treatment of infection

Treatment of complications

Slide no 33


Complications

Complications

  • Electrolyte abnormalities

  • Cerebral oedema

    • Rare but often fatal

    • Often unpredictable

    • Related to severity of acidosis, rate and amount of rehydration, severity of electrolyte disturbance, degree of glucose elevation and rate of decline of blood glucose

    • Causes raised intra-cranial pressure

  • Can lead to death

Slide no 34


Cerebral oedema 1

Cerebral Oedema (1)

  • Presents with

    • Change in neurological state (restlessness, irritability, increased drowsiness or seizures)

    • Headache

    • Increased blood pressure and slowing heart rate

    • Decreasing respiratory effort

    • Focal neurological signs

    • Diabetes insipidus: unexpected/increased urination

Slide no 35


Cerebral oedema 2

Cerebral Oedema (2)

Check blood glucose

Reduce the rate of fluid administration by one-third.

Give hypertonic saline (3%), 5 ml/kg over 30 minutes - repeat if needed

Mannitol 0.5-1 g/kg IV over 20 minutes may be an alternative

Elevate the head of the bed

Nasal oxygen

Intubation may be necessary for a patient with impending respiratory failure

Slide no 36


Monitoring

Monitoring

  • Use forms:

    • Record hourly: heart rate, blood pressure, respiratory rate, level of consciousness, glucose.

    • Monitor urine ketones

    • Record fluid intake, insulin therapy and urine output

    • Repeat urea & electrolytes every 4-6 hours

  • Once the blood glucose is less than 15 mmol/l, add dextrose to the saline

  • Transition to subcutaneous insulin

Slide no 37


Dka in summary

DKA – In Summary

Life threatening condition

Requires care at the best available facility

Morbidity and mortality reduced by early treatment

Adequate rehydration and treatment of shock crucial

Written guidelines should be available at all levels of the healthcare system

Slide no 38


Questions

Questions


Presentation title

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