DKA AND TRANSITION

By Monica Saulo

Diabetes educator nurse

TOPICS

• DEFINITION AND CAUSE
• PATHOPHYSIOLOGY
• CHARACTERISTICS.
• SIGNS AND SYMPTOMS.
• MANAGEMENT.
• PREVENTION

DEFINITION

• Medical emergency and life threatening state.
• Caused by uncorrected hyperglycemia over a long duration
• Due to lack of insulin(on admission for type 1 DM)or insufficient insulin.
• Most common in type 1DM than in type 2 DM.

DIFFERENCE BETWEEN DKA AND HHS(HYPEROSMOLAR HYPERGLYCEMIC STATE)

DKA HHS

• Common in type 1D.M Common in type 2D.M
• Develops within 24 hours(very fast) Very slowly(days to weeks)
• Blood sugar >11mmols Blood sugar>33mmols
• Ketoacidosis present(lack/enough of insulin) Absent ketoacidosis(enough insulin present )
• Dehydration Severe dehydration and high concentrated blood

PATHOPHYSIOLOGY

DIFFERENCE

• KETOSIS: breakdown of fats into energy(absence of carbohydrates)but few ketones present that doesn’t affect blood ph.
• KETOACIDOSIS :breakdown of fats(absence of carbohydrates)but ketones in excess causing acidosis.

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CHARACTERISTICS OF DKA

DIABETES KETONES ACIDOSIS

Blood sugar >11mmols Blood>or=3mmols venous pH<7.3

urine 2+ Bicarbonate<18

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SIGNS AND SYMPTOMS OF DKA

CLASSICAL SIGNS AND SYMPTOMS

• Abdominal/stomach pains.
• Deep labored breathing(kussmaul breathing).
• Vomiting.
• History of weight loss.
• Fruity –scented breath.

OTHERS SYMPTOMS

• Polyuria
• Polyphagia
• Polydipsia
• Fatigue
• Dehydration

CLASSIFICATION OF DKA

NOTE

• Admit the child in PHDU or PICU or acute room or emergency room.
• Involve other clinical team to help in the management.
• If the above not available, please can refer child but ensure initial emergency care has been commenced example airway patency or oxygenation administration and ivi fluid therapy.

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PRINCIPLE OF MANAGEMENT OF DKA

• Restoration of volume status: Correction of Shock and dehydration

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• Correction of hyperglycemia and Ketoacidosis ( insulin Therapy)

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• Correction of electrolyte imbalances

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• Management of precipitating factors

NOTE:PATIENT SHOULD BE NIL PER ORAL.

SUMMARY OF MANAGEMENT OF DKA

KEY:(1)IV FLIUD THERAPY

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(2)RAPID OR REGULAR INSULIN

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(3)BASAL INSULIN.

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(4)NPH

IV FLUIDS

• IMPORTANT PHASE OF DKA MANAGEMENT.
• Increases perfusion(utilization of glucose in the periphery).
• Corrects dehydration and prevents progressive acidosis.
• Correct the electrolytes imbalance if present.
• IF UNCERTAIN ABOUT SEVERITY OF DEHYDRATION OF DEHYDRATION,ASSUME ITS 10% DEHYDRATION

INSULIN THERAPY

• Stops lipolysis and counter-regulatory hormones.
• Increase uptake of insulin
• Stops acidosis

• ASSESSMENT :History taking- weight, age, illness duration

Physical assessment(GCS/hydration status).

• INVESTIGATIONS:BGA

Urinalysis

HbA1c

blood glucose

electrolytes

full haemogram

CRP(C-Reactive protein)

MANAGEMENT

• Patent airway , breathing and circulation.
• Give oxygen to patient in shock.
• Cannulate and get blood samples if unsuccessful do intra-osseous line.
• IN SHOCK:IVFLUID 0.9% SALINE(NORMAL SALINE) OR RINGERS LACTATE:20ML/KG for 15mins(DO 2 BOLUS)MAXIMUM 40ML/KG.
• NOT IN SHOCK:NORMAL SALINE OR RINGERS LACTATE :10-20MLS/KG FOR HOUR.
• DON’T START INSULIN UNTIL SHOCK HAS BEEN CORRECTED(INTIAL PHASES OF FLUID DONE)

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CALCULATION OF MAINTAINCE FLUID

USE OF HOLLIDAY-SEGAR FORMULAR

• 100ML/KG/DAY FOR THE 1^ST 10KG OF WEIGHT
• 50ML/KG/DAY FOR THE 2^ND 10KG OF WEIGHT
• IF WEIGHT IS OVER 20KG USE 20MLS/KG/DAY

EXAMPLE 1: CHILD’S WEIGHT 20KG

• 100ML X 10=1000ML
• 50ML X10=500ML
• TOTAL FLUID MAINTAINCE:1500MLS/24HRS

EXAMPLE 2:CHILD’S WEIGHT 40KG

• 100ML X10=1000
• 50ML X 10=500
• 20ML X20=400
• TOTAL FLUID IN 24 HRS:1900MLS

NOTE :THIS IS ONLY 24 HOURS,IF 48 HOURS MULTIPLY BY 2

CALCULATION OF DEFICIT FLUID

• FORMULAR

% DEHYDRATION X BODY WEIGHT X 10(CONSTANT NUMBER)

• EXAMPLE: child’s weight is 20kg

10%X 20kgX10=2000mls for 48 hours

NOTE

• Reassess clinical hydration regularly.

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• Once the blood glucose is less than 17 mmol/L, use 0.9% sodium chloride in 5% dextrose.(DNS)

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• Once the blood glucose is <10mmol/L, use 0.9% sodium chloride in 10% dextrose.

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• This prevents hypoglycemia.

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• Monitor serum potassium levels in UEC’S(insulin promotes entry of potassium in the cells)

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INSULIN THERAPY

• Start insulin infusion therapy one hour after initiation of fluids .
• Continuous Insulin infusion starting dose:

children >5 years 0.1 U/kg/hour,

<5 years 0.05 U/kg/hour.

• If there is no infusion pump,:-

E.g. For a 30 kg child, put 30 units of insulin in 100mls of sodium chloride and run the infusion at 10 mls/ hour to administer 0.1 Units/kg hour or run the infusion at 5 mls/ hour to administer 0.05 Units/kg/hour

• Do not give insulin as IV bolus

REMEMBER

• Plasma glucose concentration should fall at a rate of <5mmol/L/h.

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• If the rate of fall is very fast (> 5mmol/L/h, change to 0.9% sodium chloride in 5% dextrose (DNS).

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• Can increase dextrose concentration up to 12.5% if using peripheral line

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HOW TO MAKE DNS(DEXTROSE IN SALINE)

To make 0.9% sodium chloride in 5% dextrose - Take 50 mls out of 500 mls bottle of 0.9% saline and add into it 50 mls of 50 % dextrose

BICARBONATE

• BE CAREFUL HOW TO ADMINISTER BICARBONATE AS IT INCREASES RISKS OF CEREBRAL ODEMA
• GIVEN IN SEVERE ACIDOSIS IF: VENOUS PH <6.9

LIFE THREATENING HYPERKALEMIA.

IMPAIRED CARDIAC CONTRACTILITY.

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• REMEMBER PEADETRIC CONSULTANT/ENDOCRINOLOGIST/INTENSIVIST SHOULD BE AVAILABLE.

RESOLVED DKA

TRANSITIONING TO SUBCUTENOUS INSULIN

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• Oral fluids should be introduced only when substantial clinical improvement has occurred ( PH> 7.3, HCO3 >18 mmol/L).
• When ketoacidosis has resolved and oral intake is well tolerated, then change to SC insulin

NOTE

• Transition should be done before meals.

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• Basal-bolus therapy best insulin therapy

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TYPES OF INSULINS USED

BASAL INSULIN

• Given once a day (glargine –lantus) or twice a day intermediate(NPH)
• Ensure body has insulin for 24 hours.

BOLUS INSULIN

• Given before meals
• Given to correct hyperglycemia
• Types: regular insulin e.g. humilin R/actrapid
• short/rapid e.g Humalog/novorapid/apidra
• ultra-rapid e.g.lyumjev/afrezza/fiasp.

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FORMULARS FOR INSULIN DOSE

(A) BASAL-BOLUS INSULIN THERAPY/MULTIPLE DAILY INJECTION:

• PRE-PUBERTAL:0.5-0.7 UNITS/KG/DAY(TOTAL DAILY DOSE)
• PUBERTAL :0.8-1.2UNITS/KG/DAY(TOTAL DAILY DOSE)
• BASAL INSULIN(LONG ACTING INSULIN(GLARGINE):40-50% OF TDD
• BOLUS INSULIN:USE OF MEAL RATIOS AND CORRECTION FACTOR

(1)RAPID/SHORT ACTING INSULIN;CORRECTION FACTOR=100/TDD

MEAL RATIO=500/TDD

(2) REGULAR INSULIN:CORRECTION FACTOR:83/TDD

MEAL RATIOS:450/TDD

(B)REGULAR –NPH(TWICE DAILY INJECTION)

• NPH:40%of TDD
• NPH:MORNING:2/3 OF TDD AND EVENING1/3 OF TDD.
• CARBOHYDRATES COUNTING NOT APPLICABLE IN TWICE DAILY INJECTION.
• REGULAR INSULIN:60%OF TDD(IN 3 DIVIDED DOSE)
• :CORRECTION FACTOR;83/TDD .

MONITORING

• Record hourly: heart rate,

blood pressure,

respiratory rate

level of consciousness

glucose meter reading

• Monitor urine ketones in every sample of urine passed.
• Record fluid intake, insulin therapy and urine output.
• Repeat blood urea and electrolytes every 2-4 hours.
• Measure blood ketones (β-hydroxybutyrate) if possible.

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COMPLICATION OF DKA

CEREBRAL OEDEMA

• Sudden and severe headache

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Incontinence and/or vomiting

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• Combativeness, disorientation, agitation, change in mental status, posturing, seizure

• Change in vital signs
• bradycardia, hypertension

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• gasping/irregular respirations or periods of apnea

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• hypothermia

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• Pupil changes (asymmetry, sluggish), papilledema

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PREVENTION

• New onset diabetes---catch it before DKA develops
• Health care provider awareness
• Community recognition of signs and symptoms of diabetes

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• Established diabetes education on
• Access and use of insulin and test strips
• Sick day management
• Exercise management.
• Correction of hyperglycemia.

KEY MESSAGES

• It is a life threatening condition

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• Requires care at the best available facility

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• Morbidity and mortality are reduced by early treatment

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• Adequate rehydration and treatment of shock crucial

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

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THANK YOU

EROKAMANO