HWN Suggests

Episode 63 – Pediatric DKA

The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids.

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 A Sugar Rush: Managing Pediatric Diabetic Ketoacidosis

Should pediatric patients with DKA receive bicarbonate infusion to correct for acidosis? No. Bicarbonate infusions have been associated with increased risk of cerebral edema and worsening hypokalemia. The rapid correction of acidosis can also decrease the stimulus for hyperventilation and lead to increased carbon dioxide in the brain causing a decrease in cerebral pH as carbon dioxide crosses the blood-brain barrier. In very rare situations, bicarbonate can be considered, especially if the child is in severe acidosis, hemodynamically unstable, hyperkalemic, or about to go into cardiac arrest.

 Cerebral Edema and Diabetic Ketoacidosis

Cerebral edema is the most feared emergent complication of pediatric diabetic ketoacidosis. Fortunately, it is relatively rare, but the rarity can lead to some confusion when it comes to its management. We recently discussed the use of mannitol and hypertonic saline for pediatric traumatic brain injury, but when should we consider these medications for the patient presenting with DKA?

 Cerebral Edema and Diabetic Ketoacidosis: Rebaked

Cerebral edema is the most feared emergent complication of pediatric diabetic ketoacidosis. Children with moderate to severe DKA admissions have been shown to drop IQ points and it is theorized that cerebral edema is the culprit.

 Current recommendations for management of paediatric diabetic ketoacidosis

Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients.

 DKA

20 cc/kg bolus of normal saline or lactated ringers for initial fluid hydration. This will drop the serum glucose as it should help increase the patient's GFR. Patients rarely need more than this initial bolus as although they are volume depleted, the intravascular space is relatively protected as a result of hyperosmolarity. Insulin infusion (standard 0.1 u/kg/hr), generally without insulin bolus. Some advocate for lower dose insulin (0.05 u/kg/hr) for younger and/or sicker patients, as some evidence suggests there is a trend toward decreased rates of hypokalemia and hypoglycemia with no difference in time to resolution of DKA

 Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids

Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe.

 Sugar Is Bad For Kids- Pediatric DKA with Dr. George Willis

The management of diabetic ketoacidosis (DKA) in children is full of difficult questions- how much insulin should I give? Who is at risk for cerebral edema? What treatments, if any, increase the risk for this dreaded complication? Which fluid is ideal? How much of this fluid should I give? We sat down with ED physician and endocrine aficionado Dr. George Willis to answer these questions.

Articles of Interest

Cerebral Edema in Pediatric DKA, Part 2

The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis

In conclusion, in this prospective, randomized trial, neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes of diabetic ketoacidosis in children.

Current recommendations for management of paediatric diabetic ketoacidosis

Both saline and balanced crystalloids are appropriate for use as IV fluids in DKA. Balanced crystalloids (e.g., Ringer’s lactate, Plasmalyte) are recognized as safe alternatives to saline for both bolus and ongoing infusions and may minimize hyperchloremic metabolic acidosis, as well as potentially reduce CI and renal injury.

Diabetic Ketoacidosis Protocol

More-aggressive fluid boluses are suggested at the start of therapy: most patients with DKA should receive a 20-mL/kg bolus of normal saline at the beginning; those with poor cardiovascular function will require additional fluid boluses until stable. An insulin infusion rate of 0.05 U/kg/h is suggested when pH >7.15. Notation is added not to begin KCl unless patient is urinating and has plasma K+ ≤5.5 mmol/L.

DKA Like A Boss- Peds

DKA pathway and 2 bag system.

DKA Management in Kids

Pediatric DKA management has always been fraught with concern regarding fluid management due to the risk of cerebral edema. While cerebral edema is uncommon, it has devastating complications and is always in the forefront of our management techniques.

Managing Diabetic Ketoacidosis in Children

For years, clinical guidelines for the treatment of diabetic ketoacidosis have recommended limited (if any) fluid resuscitation, isotonic fluids, and slow fluid rehydration rates in order to reduce the rate of cerebral edema. A recently completed clinical trial explored the relationship between fluid replacement and cerebral injury and edema, and it provided new evidence to guide safe and effective fluid treatment for pediatric diabetic ketoacidosis.

Pediatric diabetic ketoacidosis

We feel that diabetic ketoacidosis should be approached and treated differently in children. In particular, the risk of cerebral edema is significantly higher in children and adolescents: the reported incidence ranges from 0.7% to 3%, and this complication is associated with substantial morbidity (21% to 35%) and mortality (20% to 25%).

Pediatric Diabetic Ketoacidosis: An Outpatient Perspective On Evaluation And Management

The blood glucose was dropping below 200 mg/dL, so I decreased the insulin infusion. The insulin infusion should never be decreased for falling glucose levels; rather, the amount of glucose infused should be increased by providing 10% dextrose solution so as to continue inhibition of ketogenesis and prevent hypoglycemia.

Pediatric DKA

I’m not sure about y’all but I honestly have not seen too many pediatric DKA patients. I’m assuming it probably has to do with thorough screening, but it’s important to know how it is managed because it has a couple nuances that are different than the treatment of adult patients.

Pediatric DKA: Do Fluids Really Matter?

I think based on this study and previous studies, the idea that the content and rate of administration of intravenous fluids, as well as the theory that osmotic shifts are the cause of cerebral edema are not well supported.

Pediatric DKA: Don't Fear the Fluids

Why do we fear fluids in pediatric DKA patients? Do they really cause cerebral edema or is that just what you’ve been taught for years? Did you know that with each episode of DKA children lose some memory?

Podcast 615: Pediatric DKA

While conceptually similar, treatment for pediatric DKA is overall less aggressive (no bolus of insulin, less fluids, slower corrections, etc.). Recent literature also continues to argue against cerebral edema being related to fluid management

The Rate of Resuscitation in Pediatric DKA

A few children experience cognitive impairment and cerebral edema following the resuscitation phase of diabetic ketoacidosis. For many years, there has been suspicion the rapid volume replacement with isotonic crystalloids precipitated cerebral edema, leading to protocols requiring conservative rates of fluid administration. Probably unnecessarily so.

Treatment of Pediatric Diabetic Ketoacidosis and the Two-Bag Method

Reasoning Behind the 2-Bag Method As the blood glucose levels decline, the rate of D10 “glucose bag” infusion should increase to avoid hypoglycemia. Concurrently, the saline bag infusion rate is slowed to maintain the same total 1.5 x MIVF rate. A common pitfall is to reduce the insulin infusion when the patient’s glucose levels get closer to 200 mg/dL. Instead glucose should be added to the infusion to help replete the body’s intracellular glucose stores, thus halting the production of ketoacids and the improving the patient’s bicarbonate and pH.

Resources

EM Sim Cases

DKA is a reasonably common presentation to the ED. However, it requires several important steps in its management in order to prevent harm. This is especially true in children, where the rates of cerebral edema are higher.

StatPearls

This activity reviews the etiology, presentation, evaluation, and management of diabetic ketoacidosis in the pediatric population and examines the role of the interprofessional team in evaluating, diagnosing, and managing the condition.