3a Emergency Care DKA (UK) FINAL(2)
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Transcript of 3a Emergency Care DKA (UK) FINAL(2)
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Presentation title
Emergency Care
Part 1: Managing Diabetic Ketoacidosis(DKA)
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Slide No 2Slide no 2
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Managing DKA
Surgery in children with diabetes
Treating and preventing hypoglycaemia
Programme
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Slide No 3
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 thebest available site of care with diabetes experienceInitiate care at diagnosis
Slide no 3
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Slide No 4
Type 1 Diabetes
Increased urine
Dehydration Thirst
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Slide No 5
DKA
Weight loss
Ketones
Nausea
Vomiting
Abdominal pain
Altered level ofconsciousness
Shock
Dehydration
Liver
Muscle
Fat
Weight lossKetones
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Slide No 6
Clinical features
Slide no 6
Pathophysiology(Whats wrong) Clinical features(What do you see)
Elevated bloodglucose
High lab blood glucose, glucose meterreading or urine glucose, polyuria,polydypsia
Dehydration Sunken eyes, dry mouth, decreasedskin turgor, decreasedperfusion (shock rare)
Altered electrolytes Irritability, change in level ofconsciousness
Metabolic acidosis(ketosis)
Acidotic breathing, nausea, vomiting,abdominal pain, altered level ofconsciousness
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Slide No 7
Managing DKA
Refer to best available site of care whenever possible
Need:
Appropriate nursing expertise (preferably a high level ofcare)
Laboratory support
Clinical expertise in management of DKA
Written guidelines should be available
Document and use the form
Slide no 7
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Slide No 8
DKA monitoring form
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Slide No 9
DKA monitoring
DKA protocol available to the clinic
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Slide No 10
Principles of DKA management (1)
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 10
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Slide No 11
Principles of DKA Management (2)
1. Correction of shock or decreased peripheralcirculation quick phase
2. Correction of dehydration - slow phase
Do not start insulin until the child has beenadequately resuscitated, i.e. good perfusion and
good circulation
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Slide No 12
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 12
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Slide No 13
Assessment
History and examination including:
Severity of dehydration. If uncertain about this, assume10% 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
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Slide No 14
Resuscitation (1)
Ensure appropriate life support (Airway, Breathing,Circulation, etc.)
Give oxygen to children with impaired circulation and/orshock
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. Repeatboluses of 10 ml/kg until perfusion improves
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Slide No 15
Resuscitation (2)
If no IV available, insert nasogastric tube or set upintraosseous or clysis infusion
Give fluid at 10 ml/kg/hour until perfusion improves, then5 ml/kg/hour
Use normal saline, half-strength Darrows solution withdextrose, or oral rehydration solution
Decrease rate if child has repeated vomiting
Transfer to appropriate level of care
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Slide No 16
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 16
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Slide No 17
Rehydration (1)
Rehydrate with normal saline
Provide maintenance and replace a 10% deficit over 48hours
Do not add urine output to the replacement volume
Reassess clinical hydration regularly.
Once the blood glucose is
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Slide No 18
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 sipsat a rate of 1 ml/kg every 5 min if decreased peripheralcirculation, otherwise every 10 min.
Arrange transfer of the child to a facility withresources to establish intravenous access as soonas possible
Slide no 18
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Slide No 19
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 19
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Slide No 20
Insulin therapy (1)
Start insulin after your ABCs (treat shock, start fluids) -stability has improved
Insulin infusion of any short acting insulin at0.1U/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 of5 mmol/l per hour
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Slide No 21
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 at10 ml/hour
Equivalent to 0.1 U/kg/hour
Younger children: lower rate e.g. 0.05 U/kg/hour
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Slide No 22
Insulin therapy (3)
If no suitable control of the rate of the insulin infusionis 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 withresources to establish intravenous access as soon
as possible
Slide no 22
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Slide No 23
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
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Slide No 24
Electrolyte deficits
The most important is potassium
Every child in DKA needs potassium replacement
Other electrolytes can only be assessed with alaboratory test
Obtain a blood sample for determination of electrolytesat diagnosis of DKA
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Slide No 25
ECG and Potassium Levels
l dl d
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Slide No 26
Potassium (1)
Levels determined by laboratory test
If not available, can use ECG (T waves)
Start potassium replacement once serum value knownor patient passes urine
If no lab value or urine output within 4 hours of startinginsulin, start potassium replacement
Slide no 26
Slid N 27Slid 27
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Slide No 27
Potassium (2)
Add KCl to IV fluids at a concentration of 40 mmol/l (20ml of 15% KCl has 40 mmol/l of potassium)
If IV potassium not available, replace by giving thechild fruit juice or bananas.
If rehydrating with oral rehydration solution (ORS), noadded potassium is needed
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Slide No 28
Potassium (3)
Monitor serum potassium 6-hourly, or as often as ispossible
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
Slide No 29Slide no 29
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Slide No 29
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 29
Slide No 30Slide no 30
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Slide No 30
Acidosis
Usually due to ketones
Poor circulation will make it worse
Correction not recommended unless the acidosis is veryprofound
If bicarbonate is considered necessary, cautiously give1-2 mmol/kg over 60 minutes. Usually not needed
Slide no 30
Slide No 31Slide no 31
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Slide No 31
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 31
Slide No 32Slide no 32
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Slide No 32
Infection
Infection can precipitate the development of DKA
Often difficult to exclude infection in DKA, as the whitecell count is often elevated because of stress
If infection is suspected, treat with broad-spectrum
antibiotics
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Slide No 33Slide no 33
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Slide No 33
Principles
1. Correction of shock
2. Correction of dehydration
3. Correction of hyperglycaemia
4. Correction of deficits in electrolytes
5. Correction of acidosis
6. Treatment of infection
7. Treatment of complications
Slide no 33
Slide No 34Slide no 34
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Slide No 34
Complications
Electrolyte abnormalities
Cerebral oedema
Rare but often fatal
Often unpredictable
Related to severity of acidosis, rate and amount ofrehydration, severity of electrolyte disturbance, degreeof glucose elevation and rate of decline of blood glucose
Causes raised intra-cranial pressure
Can lead to death
Slide no 34
Slide No 35Slide no 35
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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
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Cerebral Oedema (2)
Check blood glucose
Reduce the rate of fluid administration by one-third.
Give hypertonic saline (3%), 5 ml/kg over 30minutes - repeat if needed
Mannitol 0.5-1 g/kg IV over 20 minutes may be analternative
Elevate the head of the bed
Nasal oxygen
Intubation may be necessary for a patient withimpending respiratory failure
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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, adddextrose to the saline
Transition to subcutaneous insulin
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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 ofthe healthcare system
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Questions
Slide No 40
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