Treatment of diabetic ketoacidosis with subcutaneous. Professor, department of pediatrics, division of pediatric endocrinology, johns hopkins university school of medicine, baltimore, md after completing this article, readers should be able to. The joslin clinical nutrition guideline for overweight and obese adults with type 2 diabetes, prediabetes or those at high risk for developing type 2 diabetes is designed to assist primary care physicians, specialists, and other healthcare providers in individualizing the care of and set goals for adult, nonpregnant patients with type 2 diabetes or individuals at high risk for developing type. Dka that ensues is an example of a superfasted state. Diabetic ketoacidosis dka critical care guideline two bag. For pediatric dka sites follow algorithm below for two plus. If protocol contraindicated or not ordered, notify physician. A consensus statement from the international society for pediatric and adolescent. This intrigued us to look into other hospitals practices and into the evidence behind these practices. We hypothesized that development and utilization of standard work for inpatient care of dka would lead to reduction in hypokalemia and improvement in outcome measures. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Can children with mild diabetic ketoacidosis be managed. The diabetes with dka clinical pathway is a detailed plan of the course of care for pediatric patients seen in the emergency department with diabetic ketoacidosis. Wrnmmcb pediatric diabetic ketoacidosis clinical practice.
Diabetic ketoacidosis american academy of pediatrics. The optimal protocol for intravenous iv fluid administration is an area of particular controversy, mainly in regard to possible associations between rates of iv fluid infusion and the development of cerebral edema ce, the most common and the most feared complication of. Diabetic ketoacidosis dka in children and adolescents has a mortality rate of 1% to 2%. Dka sample physician order sheet dka glucose, fluid and insulin management dka nursing protocol including the twobag method dka recipes for making solutions. Children were randomly assigned to one of four treatment groups in a 2by2 factorial design 0. Those with severe dka have a much higher mortality and risk of complications. The biochemical criteria for the diagnosis of diabetic ketoacidosis dka are. Our goal was to describe our longterm experience in the. Ispad clinical practice consensus guidelines 2014 compendium. Management and treatment of pediatric type 1 diabetes.
Diabetic ketoacidosis dka care guidelines emergency. Outpatient or inpatient care child with new dm diagnosis. We sought to create and implement recommendations from an evidencebased pathway for hospital management of pediatric diabetic ketoacidosis dka and to sustain improvement. Choose one of the access methods below or take a look at our subscribe or free trial options. No protocol for dka has been shown to eliminate the risk of cerebral oedema and this guideline is based on. Completing more than 20,000 ambulatory encounters per year, bdc is the largest outpatient. Consumption of freefatty acids leads the formation of ketoacids and precipitates a. A subscription is required to access all the content in best practice. Wrnmmcb pediatric diabetic ketoacidosis clinical practice guideline 1. Pediatric diabetic ketoacidosis, fluid therapy and cerebral. Dka without a preceding febrile illness or gastroenteritis in a patient with known diabetes is almost always the result of psychosocial problems and failure to appropriately administer insulin.
The criteria for hyperglycemic hyperosmolar state hhs include. Almost 1 in 100 children with dka will develop cerebral edema, which has a mortality rate of 2124%. In new onset diabetes, dka is frequently the consequence of a delay in diagnosis e. Barbara davis center serves more than 90% of colorado children diagnosed with type 1 diabetes. It is intended to be a reference for clinicians caring. Criteria and overview pathophysiology of dka explanation of evidence ratings summary of version changes inclusion criteria dka is defined as need all 3 criteria. Pediatric diabetic ketoacidosis dka treatment guide childrens. Dka at diagnosis is more common in children dka represents a profound insulindeficient state characterized by hyperglycemia 200 mgdl 11. Many of the details about the risk factors as well as the mechanisms leading to dka related cerebral edema are not. Treatment of diabetic ketoacidosis with subcutaneous insulin. The bc childrens hospital diabetic ketoacidosis dka protocol has now been.
Diabetic ketoacidosis and hyperglycemic hyperosmolar state asped. Near patient testing for the ketones is now readily available for monitoring allowing for a shift away from using glucose levels to drive treatment decisions in the management of dka. Patients identified with diabetic ketoacidosis during their hospital stay background definitions diabetic ketoacidosis dka is a lifethreatening condition. Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7.
The optimal protocol for intravenous fluid administration is an area of particular controversy, mainly in regard to possible associations between rates of intravenous fluid infusion and the development of cerebral. Pediatric diabetic ketoacidosis dka treatment guide. Ua, cbc, serum osm, hgba1c, lft, mg, phos, amylase, lipase do not delay treatment while obtaining labs abcs, gcs. Diabetes type 1, with dka clinical pathway emergency. Paediatric management of diabetic ketoacidosis dka squarespace. The most feared complication in the clinical course of children with diabetic ketoacidosis dka is the development of cerebral edema. Click to learn how to make a referral and who to contact locally to get your patient connected to these services. Glucose 200 mgdl and venous ph pediatric care coordination resource guide the pediatric care coordination resource guide is designed to help identify appropriate candidates for care coordination and care management services.
Many of the details about the risk factors as well as the mechanisms leading to dka related cerebral edema are not well understood. The information is believed, but not guaranteed to be correct. Division of critical care, department of pediatrics, childrens hospital of wisconsinmedical college of wisconsin, milwaukee, wi abbreviations. Describe the typical presentation of diabetic ketoacidosis. Correct ketosis and acidosis with continuous insulin. Divisions of pediatric emergency medicine and endocrinology date of approval. Children with severe dka long duration of symptoms, compromised circulation, or depressed level of consciousness or those who are at increased risk for cerebral edema eg, pediatric if available or in. Diabetic ketoacidosis dka is a complex metabolic state of hyperglycemia, ketosis, and acidosis, which results from untreated absolute or relative deficiency of insulin, respectively, in type 1 or type 2 diabetes mellitus. Dka frequency at the time of diagnosis of pediatric diabetes is 10%70%, varying with the. The pediatric emergency care applied research network fluid fluid therapies under investigation in dka study is the. The clinical guidelines and references provided on this website are developed by the department of emergency medicine at maine medical center. Peds morsels blog on cerebral edema in diabetic ketoacidosis.
Emergency department management clinical practice guideline cpg protocol approved by. Unc pediatric dka guidelines this is a general guideline and does not represent a professional care standard governing providers obligations to patients. Red deer regional hospital diabetic ketoacidosis dka pediatric protocol. As a result, freefatty acids are used as the primary energy source. Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. According to the search for diabetes in youth study, over the past ten years bdc provided care to 3,222 of the 3,500 children who were diagnosed in colorado. This is a quality improvement document and should not. Dka usually occurs as a consequence of absolute or relative insulin deficiency that is accompanied by an increase in counter. Pediatric diabetes ispad clinical practice consensus guidelines 2014 compendium diabetic ketoacidosis and hyperglycemic hyperosmolar state wolfsdorf ji, allgrove j, craig me, edge j, glaser n, jain v, lee wwr, mungai lnw, rosenbloom al, sperling ma, hanas r.
Diabetic ketoacidosis dka childrens hospital colorado. Enhance resident management of pediatric dka and improve patient safety. This is a quality improvement document and should not be part of the patients medical record. It reflects our expert opinion and is not necessarily applicable to all institutions. Diabetic ketoacidosis dka critical care guideline two. Does protocol implementation decrease length of stay in. The management of dka in children is summarized clinical features and diagnosis of diabetic ketoacidosis in children and adolescents view in chinese. Ada1,chi management and treatment of pediatric type 1 diabetes care process model february 2017. Mild dka was previously defined in the international society for pediatric and adolescent diabetes guidelines as a ph of 7. Dka is the leading cause of death in children with type 1 diabetes 1, 2 and accounts for a significant proportion of admissions in adult patients with type 1 or type 2 diabetes 1, 3. The biochemical criteria for the diagnosis of diabetic ketoacidosis.
Click to find referral pathways, guidelines and contact information. The authors created a working definition that incorporates both biochemical and social factors. Diabetic ketoacidosis dka is the leading cause of morbidity and mortality in children with type 1 diabetes, with a case fatality rate ranging from 0. Pathophysiology diabetic ketoacidosis dka is a complex disordered metabolic state characterised by hyperglycaemia, acidosis, and ketonaemia. The management of diabetic ketoacidosis in children. Barbara davis center home university of colorado school. Diabetic ketoacidosis dka is the metabolic abnormality of type 1 diabetes. Pediatric diabetic ketoacidosis, fluid therapy, and. The pediatric specialists at maine medical partners and the barbara bush childrens hospital have created pediatric referral guidelines to help you provide better care for your patients. Diabetic ketoacidosis, pediatric emergency and inpatient. Emergency care applied research network pecarn dka fluid study group.
Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the usa and. The purpose of this project was to examine the effectiveness in a dka protocol and, based off that evidence, to begin the process of enacting a dka protocol on inova s pediatric. Dka is most commonly seen in patients with type 1 diabetes since the disease is defined by insulin deficiency. Morales, md associate professor of pediatrics barnstable brown diabetes center uk healthcare june 15, 2019 faculty disclosure no relevant financial relationships to disclose. This cpm is based on guidelines from the american diabetes association ada, particularly the 2014 position statement type 1 diabetes through the life span, as well as the opinion of local clinical experts in pediatric diabetes. Pediatric dka protocol this protocol is intended as a guide individual patient modifications may be necessary. Diabetic ketoacidosis dka represents a profound insulinde. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. Objective in this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard lowdose intravenous iv infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis dka. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury. Dka development is intrinsically tied in with dysregulation of these systems. Pediatric diabetic ketoacidosis dka treatment guide condition not dka mild dka moderate dka severe dka hco 3 meql 15 to 33 less than 15 less than 10 less than 5 venous ph 7. Dka treatment protocol barbara davis center for childhood.
Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the usa and worldwide. On page 2 of dka critical care guidelines cerebral edema treatment give mannitol 0. Pdf the management of diabetic ketoacidosis in children. Reevaluate appropriateness of replacement fluid type frequently. Cerebral edema may be present at the time of initial assessment or. Diabetic ketoacidosis, pediatric emergency and inpatient v 1. The proper management of dka requires intense monitoring and clear understanding of pathophysiology related to it.
Dka frequency at the time of diagnosis of pediatric diabetes is. For more information refer to chqgdl60016 diabetic ketoacidosis dka emergency management in children dka emergency management in children flowchart child with dka diagnosis bgl11 mmoll, ph pediatric dka. Dka also can occur in children with type 2 diabetes. Clinical guideline childrens hospital of richmond at vcu. Potential complications include cerebral edema, hypokalemia, hypoglycemia, and relapse. Dka red flags, risk factors, considerations for picu admission. Management of diabetic ketoacidosis in children and. Diabetic ketoacidosis in children descriptionetiology diabetic ketoacidosis dka is a lifethreatening medical emergency brought on by severe insulin deficiency, which usually results in hyperglycemia i.
Pediatric diabetic ketoacidosis and hyperglycemic hyperosmolar state. Treatment of pediatric diabetic ketoacidosis in canada. Off algorithm, look for alternative diagnosis initiate dka powerplan and send labs. Division of critical care, department of pediatrics, childrens hospital of michiganwayne state university school of medicine, detroit, mi 2. Pdf management of diabetic ketoacidosis in children and. The dka medical protocol can also be downloaded in fillable pdf format. Diabetes type 1, with dka clinical pathway emergency childrens hospital of philadelphia. The guidelines included on this page have been commissioned and endorsed by the bsped and reflect the societys views on best practice for the majority of patients with that condition. The lack of insulin prevents glucose from being used as an energy source. This version autocalculates the fluid rates and has some popup screens to guide in the clinical evaluation of children presenting with dka. The management of diabetic ketoacidosis in children ncbi. Following the publication of the pekarn dka fluid trial new engl j med 2018. Apr 25, 2014 diabetic ketoacidosis, together with the major complication of cerebral edema, is the most important cause of mortality and severe morbidity in pediatric cases of diabetes, particularly at the time of first diagnosis.
1008 1304 912 478 1114 733 1308 329 862 1318 370 1315 988 1222 1312 1059 1260 652 623 290 804 1331 562 1386 232 1187 945 1340 280 1246