Diabetic Ketoacidosis in Children and Young People up to 18 years NHSCT/10/358

Transcription

Guidelines for the Management of Diabetic Ketoacidosis in Children and Young People up to 18 years
This is an official Northern Trust policy and should not be edited
in any way
Diabetic Ketoacidosis in Children and
Young People up to 18 years
Reference Number:
NHSCT/10/358
Target audience:
Medical and Nursing Staff
Sources of advice in relation to this document:
Dr Caroline Stewart, Consultant Paediatrician
Dr Mark Rollins, Consultant Paediatrician
Dr Desmond Rooney, Consultant Physician
Dr Adele Kennedy, Consultant Physician
Dr Julian Leggett, Consultant Physician
Dr Peter Flanagan, Medical Director
Replaces (if appropriate):
Replaces previous National / International guidelines of BSEPD/ISPAD DKA
Management 2004 which were used throughout the Province.
Reference - (Archives of Disease in Childhood, 2004, 89: 188 -194)
Type of Document: Trust Wide
Approved by:
Policy, Standards and Guidelines Committee
Date Approved:
12 August 2010
Date Issued by Policy Unit:
25 November 2010
(Revised May 2011 and replaced on Staffnet only)
NHSCT Mission Statement
To provide for all, the quality of service we expect for our families, and ourselves.
Management of Diabetic Ketoacidosis in Children
and Young People up to 18 years
NHSCT – August 2010
(BSPED Recommended DKA Guidelines November 2009)
Management of Diabetic Ketoacidosis in Children and Young People up to 18 years
These guidelines for the management of Diabetic Ketoacidosis were originally produced by a working
group of the British Society of Paediatric Endocrinology and Diabetes. Modifications have been made in
the light of the ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents
(Archives of Disease in Childhood, 2004, 89: 188-194) and the recent guidelines produced by the
International Society for Paediatric and Adolescent Diabetes (Paediatric Diabetes, 2007, 8: 28-43).
These guidelines are believed to be as safe as possible in the light of current evidence. However, no
guidelines can be considered entirely safe as complications may still arise. In particular the
pathophysiology of cerebral oedema is still poorly understood.
For the evidence-base to the management guidelines, please see the ISPAD guidelines;
http://www.ispad.org/FileCenter/ISPAD%20Guidelines%202009%20-%20DKA.pdf and Chapter 4 of
Evidence-based Paediatric and Adolescent Diabetes, Eds Allgrove, Swift & Greene, Blackwell
Publishing, ISBN 978-1-4051-5292-1.
The following changes have been made since the last version (2004)
1.
2.
3.
4.
Recommendation to use capillary blood ketone measurement during treatment.
Reduction in the degree of dehydration to be used to calculate fluids.
Reduction in maintenance fluid rates.
Change in the recommendations for PICU/HDU – more emphasis on safe nursing on general
wards.
5. Continuation of Normal saline for the first 12 hours of rehydration.
6. Delay in insulin until fluids have been running for an hour.
7. Option to continue insulin glargine during treatment.
8. Reminder to stop insulin pump therapy during treatment.
9. Reminder to consider anticoagulant prophylaxis in young children, especially those with femoral
lines.
10. Interpretation of blood ketone measurements if pH not improving.
11. Option to use hypertonic saline instead of mannitol for the treatment of cerebral oedema.
The associated fluid calculation spreadsheet was designed by Dr Andrew Durward, and the flow-charts
for results by Dr Nandu Thalange. The Integrated Care Pathway has been produced by the South West
Diabetes Group, with minor modifications to take account of recent changes to the Guidelines (Dr
Christine Burren).
Any information relating to use of these guidelines would be very valuable. Please address any
comments to:
Dr Julie Edge, Consultant in Paediatric Diabetes, Oxford Children’s Hospital, Headington, Oxford, OX3
9DU.
1
Contents
Page
A.
General comments
3
B.
Emergency management
1. Resuscitation
2. Confirm diagnosis
3. Investigations
C.
Full Clinical Assessment
1.
2.
3.
4.
5.
D.
4
4
4
Assessment of dehydration
Conscious level
Physical examination
Role of PICU
Observations to be carried out
5
5
5
5
6
Management
1. Fluids
6
2. Potassium
3. Insulin
4. Bicarbonate
5. Phosphate
6. Anticoagulant prophylaxis
6
7
8
8
8
9
9
9
E.
Continuing management
10
F.
Cerebral oedema
G.
volume
Type
Oral fluids
Features
Management
10
11
Other complications and associations
11
Glasgow Coma Scale
Appendix 1
12
Algorithm for Management
Appendix 2
13
Summary DKA Guidelines
Appendix 3
14
Algorithm for referral by age
Appendix 4
15
2
Target Audience
Medical and Nursing Staff.
A.
General
Always accept any referral and admit children in suspected DKA.
Always consult with a more senior doctor on call as soon as you suspect DKA even if you feel
confident of your management.
Remember:
children can die from DKA.
They can die from –
Cerebral oedema
Hypokalaemia
Aspiration pneumonia
This is unpredictable, occurs more frequently in younger
children and newly diagnosed diabetes and has a
mortality of around 25%. The causes are not known, but
this protocol aims to minimise the risk by producing a slow
correction of the metabolic abnormalities. The
management of cerebral oedema is covered on page 11.
This is preventable with careful monitoring and
management.
Use a naso-gastric tube in semi-conscious or unconscious
children.
These are general guidelines for management. Treatment may need modification to suit the individual
patient and these guidelines do not remove the need for frequent detailed reassessments of the
individual child’s requirements.
These guidelines are intended for the management of children and young people who have:
and who are
Hyperglycaemia (BG > 11 mmol/l)
pH < 7.3 or Bicarbonate < 15 mmol/l
Ketonemia and ketonuria
•
•
•
•
more than 3% dehydrated
and/or vomiting
and/or drowsy
and/or clinically acidotic
Children who are 5% dehydrated or less and not clinically unwell (mild acidosis and not nauseated or
vomiting) usually tolerate oral rehydration and subcutaneous insulin.
Blood ketone levels are generally over 3.0 mmol/l but some well children who do not fulfil the criteria
above for IV fluids may have ketone levels of up to 6.0mmol/l.
Discuss this with the senior doctor on call.
All staff must recognise the needs of close family during resuscitation of a loved one.
Staff should explain the treatment plan to the parents of the child admitted to their care (and also to the
young person when appropriate).
3
B.
Emergency Management in A&E
1.
General Resuscitation: A, B, C.
Airway
Ensure that the airway is patent. If the child is comatose, or has reduced level of
consciousness and recurrent vomiting, their airway needs to be protected. Request help
early from anaesthetic team to secure airway before attempting to insert N/G tube. This
should be left on open drainage.
Breathing
Give 100% oxygen by face-mask.
Circulation
Insert IV cannula and take blood sample (see below). Cardiac monitor for T waves
(peaked in hyperkalaemia)
Only if shocked (poor peripheral pulses, poor capillary filling with tachycardia, and/or hypotension) give
10 ml/kg 0.9% sodium chloride as a bolus, and repeat as necessary to a maximum of 30 ml/kg.
(There is no evidence to support the use of colloids or other volume expanders in preference to
crystalloids).
2.
Confirm the Diagnosis:
History
Clinical
Polydipsia, polyuria
Acidotic respiration
Dehydration
Drowsiness
Abdominal pain/vomiting
Biochemical
High blood glucose (>11 mmol/l)
Blood pH<7.3 and/or HCO3 <15 mmol/l
Blood ketones > 3.0mmol/l or ketones in urine
3.
Initial Investigations:
•
•
•
•
blood glucose (Glucose measurement on blood gas machine is accurate)
urea and electrolytes (also accurate from blood gas machine)
blood gases (venous blood gives very similar pH and pCO2 to arterial)
near patient blood ketones if available (superior to urine ketones)
+/- other investigations only if indicated e.g. PCV and full blood count (leucocytosis is common in DKA
and does not necessarily indicate sepsis), CXR, CSF, throat swab, blood culture, urinalysis, culture and
sensitivity etc.
(DKA may rarely be precipitated by sepsis, and fever is not part of DKA)
Children and young people who are acutely unwell with DKA should always go to A&E for initial
emergency management before being admitted to a ward.
4
C.
Full Clinical Assessment And Observations:
Assess and record in the notes, so that comparisons can be made by others later.
1.
Degree of Dehydration
Mild, 3%
Moderate 5%
Severe 8%
+ shock
is only just clinically detectable
dry mucous membranes, reduced skin turgor
above with sunken eyes, poor capillary return
may be severely ill with poor perfusion, thready rapid pulse
(reduced blood pressure is not likely and is a very late sign)
Over-estimation of degree of dehydration is dangerous.
Therefore do not use more than 8% dehydration in calculations
2.
Conscious Level
Institute hourly neurological observations including Glasgow Coma Score (see Appendix 1) whether or
not drowsy on admission.
If in coma on admission, or there is any subsequent deterioration,
• consider transfer to PICU (in RBHSC up to 13th birthday) / ICU/HDU (in Antrim/Causeway if
over 13 years) if available
• request anaesthetic opinion ASAP if there is any question of cerebral oedema
• consider instituting cerebral oedema management (if high level of suspicion, start treatment prior
to transfer) (page 11)
• coma is directly related to degree of acidosis, but signs of raised intracranial pressure suggest
cerebral oedema
3.
Full Examination – looking particularly for evidence of •
cerebral oedema
•
•
Infection
Ileus
headache, irritability, slowing pulse, rising blood pressure,
reducing conscious level N.B papilloedema is a late sign.
WEIGH THE CHILD. If this is not possible because of the clinical condition, use the most recent clinic
weight as a guideline or an estimated weight from centile charts.
4.
•
•
•
•
•
Consider PICU or HDU for the following, and discuss with a PICU consultant
severe acidosis pH<7.1 with marked hyperventilation
severe dehydration with shock
depressed sensorium with risk of aspiration from vomiting
very young (under 2 years)
staffing levels on the wards are insufficient to allow adequate monitoring
N.B. Where PICU or HDU do not exist within the admitting hospital, transfer to another hospital
for such care (unless ventilatory support becomes necessary) may not be appropriate. However,
ALL children with DKA are high-dependency patients and require a high level of nursing care,
usually 1:1 even if on general paediatric wards.
5
5.
Observations to be carried out
Ensure full instructions are given to the senior nursing staff emphasising the need for:
•
•
•
•
•
•
•
•
•
strict fluid balance (urinary catheterisation may be required in young/sick children)
measurement of volume of every urine sample
hourly blood glucose measurements (capillary blood glucose may be inaccurate with severe
dehydration/acidosis but useful in documenting the trends. Do not rely on any sudden changes but
check with a venous blood gas instrument or laboratory glucose measurement).
Blood ketone levels every 1-2 hours (if available) – see section E below
urine testing for ketones (if blood ketone testing not available)
hourly BP and basic observations
twice daily weight; can be helpful in assessing fluid balance
hourly or more frequent neurological observations initially
reporting immediately to the medical staff, even at night, symptoms of headache, or slowing of
pulse rate, or any change in either conscious level or behaviour
Start recording all results and clinical signs on a flow chart. An example is shown on line (flow
chart) - see www.bsped.org.uk/professional/guidelines/docs/DKAFlowchart.pdf.
D.
MANAGEMENT:
1.
FLUIDS:
N.B
It is essential that all fluids given are documented carefully, particularly the fluid which is given in
Casualty and on the way to the ward, as this is where most mistakes occur.
Check all fluid calculations with another member of staff.
a)
Volume of Fluid -
By this stage, the circulating volume should have been restored and the child no longer in shock. If not,
give a further 10ml/kg 0.9% sodium chloride (to a maximum of 30ml/kg) over 30 minutes. (Discuss with
a consultant if the child has already received 30ml/kg).
Otherwise, once circulating blood volume has been restored, calculate fluid requirements as follows
Requirement = Maintenance + Deficit – fluid already given
Deficit (ml) = % dehydration x body weight (kg) x 10
For most children, use 5% to 8% dehydration to calculate fluids
Maintenance requirements:
Weight
0-12.9kg
13-19.9kg
20-34.9kg
35-59.9kg
Adult (>60kg)
80ml/kg/24hrs
65ml/kg/24hrs
55ml/kg/24hrs
45ml/kg/24hrs
35ml/kg/24hrs
N.B
Neonatal DKA will require special consideration and larger volume of fluid than those quoted may
be required, usually 100-150ml/kg/24hours)
6
N.B
APLS maintenance fluid rates over-estimate requirement, particularly at younger ages. Add
calculated maintenance (for 48 hours) and estimated deficit, subtract the amount already given as
resuscitation fluid, and given the total volume evenly over the next 48 hours i.e.
Hourly rate = 48hr maintenance + deficit – resuscitation fluid already given
48
Example:
A 20kg 6 year old boy who is 8% dehydrated, and who has already had 20ml/kg 0.9% sodium chloride,
will require
8(%) X 20(Kg) X 10 =
1600mls deficit
plus 55mls x 20kg = 1100mls maintenance each 24 hours
1100mls
= 3800mls
minus 20kg x 20ml = 400mls resus fluid
3400 mls over 48 hours = 71 mls/hour
Do not include continuing urinary losses in the calculations at this stage
For a method of calculating fluid rates which can be printed out for the child’s medical records,
use this link (fluid Calculator):
www.bsped.org.uk/professional/guidelines/docs/DKACalculator.pdf
b)
Type of fluid -
Initially use 0.9% sodium chloride + 20mmol Potassium Chloride in 500ml, and continue this
sodium concentration for at least 12 hours.
Once the blood glucose has fallen to 14mmol/l add glucose to the fluid.
A bag of 500ml 0.9% sodium chloride with 5% glucose and 20 mmol Potassium Chloride should be
available from Pharmacy. If not, make up a solution as follows – withdraw 50ml 0.9% sodium
chloride/Potassium Chloride from 500ml bag, and add 50ml of 50% glucose (this makes a solution which
is approximately 5% glucose with 0.9% sodium chloride with potassium).
After 12 hours, if the plasma sodium level is stable or increasing, change to 500ml bags of 0.45%
sodium chloride + 5% glucose + 20mmol Potassium Chloride.
If the plasma sodium is falling, continue with 0.9% sodium chloride (with or without glucose depending
on blood glucose levels). Some have suggested that Corrected Sodium levels give an indication of the
risk of cerebral oedema. Calculation for corrected sodium can be found on:
http://www.strs.nhs.uk/resources/pdf/guidelines/correctedNA.pdf.
or by using the formulae Corrected Na = Na + 0.4 ([Glucose] - 5.5).
Corrected sodium levels should rise as blood glucose levels fall during treatment. If they do not, then
continue with 0.9% sodium chloride and do not change to 0.45% sodium chloride.
Check U & E’s 2 hours after resuscitation is begun and then at least 4 hourly.
Electrolytes on blood gas machine are as good and reliable as laboratory based tests.
The following solutions should soon be available from pharmacies:
500ml bag of 0.45% sodium chloride + 5% glucose containing 20mmol Potassium Chloride
500ml bag of 0.9% sodium chloride + 5% glucose containing 20 mmol Potassium Chloride
7
c)
Oral Fluids:
•
•
•
2.
In severe dehydration, impaired consciousness & acidosis do not allow fluids by mouth. An N/G
tube may be necessary in the case of gastric paresis.
Oral fluids (e.g. fruit juice/oral rehydration solution) should only be offered after substantial clinical
improvement and no vomiting.
When good clinical improvement occurs before the 48hr rehydration period is completed, oral
intake may proceed and the need for IV infusions reduced to take account of the oral intake.
POTASSIUM:
Once the child has been resuscitated, potassium should be commenced immediately with rehydration
fluid unless anuria is suspected. Potassium is mainly an intracellular ion, and there is always massive
depletion of total body potassium although initial plasma levels may be low, normal or even high. Levels
in the blood will fall once insulin is commenced.
Therefore ensure that every 500ml bag of fluid contains 20mmol Potassium Chloride (40mmol per
litre). There may be standard bags available; if not, strong potassium solution may need to be added,
but always check with another person.
Check U & E’s 2 hours after resuscitation is begun and then at least 4 hourly, and alter potassium
replacements accordingly. More potassium than 40mmol/l is occasionally required.
Use a cardiac monitor and observe frequently for T wave changes.
3.
INSULIN:
Once rehydration fluids and potassium are running, blood glucose levels will start to fall. There is some
evidence that cerebral oedema is more likely if insulin is started early. Therefore DO NOT start insulin
until intravenous fluids have been running for at least an hour.
Continuous low-dose intravenous infusion is the preferred method. There is no need for an initial
bolus.
Make up a solution of 1 unit per ml of human soluble insulin (e.g. Actrapid) by adding 50 units (0.5ml)
insulin to 50 ml 0.9% sodium chloride in a syringe pump. Attach this using a Y-connector to the IV fluids
already running. Do not add insulin directly to the fluid bags.
The solution should then run at 0.1 units/kg/hour (0.1ml/kg/hour). There are some paediatricians who
believe that 0.05 units/kg/hour is an adequate dose. There is no firm evidence to support this.
•
•
•
•
Once the blood glucose level falls to 14mmol/l (on blood gas machine or laboratory test),
change the fluid to contain 5% glucose (generally 0.9% sodium chloride with glucose and
potassium, see 1b above for type of fluid). DO NOT reduce the insulin. The insulin dose needs
to be maintained at 0.1 units/kg/hour to switch off ketogenesis.
Some suggest also adding glucose if the initial rate of fall of blood glucose is greater than 5-8
mmol/l per hour, to help protect against cerebral oedema. There is no good evidence for this
practice, and blood glucose levels will often fall quickly purely because of rehydration.
DO NOT stop the insulin infusion while glucose is being infused, as insulin is required to switch
off ketone production. If the blood glucose falls below 4 mmol/l, (on blood gas machine or
laboratory test), give a bolus of 2 ml/kg of 10% glucose and increase the glucose concentration
of the infusion. Insulin can temporarily be reduced for 1 hour.
If needed, a solution of 10% glucose + 0.45% sodium chloride can be made up by adding
50ml 50% glucose to a 500ml bag of 0.45% sodium chloride + 5% glucose with 20 mmol
Potassium Chloride.
8
•
•
Once the pH is above 7.3, the blood glucose is down to 14 mmol/l, and a glucose-containing
fluid has been started, consider reducing the insulin infusion rate, but to no less than 0.05
units/kg/hour.
If the blood glucose rises out of control, or the pH level is not improving after 4-6 hours consult
senior medical staff and re-evaluate (possible sepsis, insulin errors or other condition), and
consider starting the whole protocol again.
For children who are already on long-acting insulin (especially Glargine (Lantus)), your local
consultant may want this to continue at the usual dose and time throughout the DKA treatment, in
addition to the IV insulin infusion, in order to shorten length of stay after recovery from DKA.
For children on continuous subcutaneous insulin infusion (CSII) pump therapy, stop the pump
when starting DKA treatment.
4.
BICARBONATE:
This is rarely, if ever, necessary. Continuing acidosis usually means insufficient resuscitation or
insufficient insulin. Bicarbonate should only be considered in children who are profoundly acidotic
(pH<6.9) and shocked with circulatory failure. Its only purpose is to improve cardiac contractility in
severe shock.
Before starting bicarbonate, discuss with senior staff, and the quantity should be decided by the
paediatric resuscitation team or consultant on-call.
5.
PHOSPHATE:
There is always depletion of phosphate, another predominantly intracellular ion. Plasma levels may be
very low. There is no evidence in adults or children that replacement has any clinical benefit and
phosphate administration may lead to hypocalcaemia.
However, the severely hypophosphataemic patient (risk of cardiac arrest etc) may be missed if
phosphate is not monitored during the treatment and recovery phase of severe DKA.
6.
ANTICOAGULANT PROPHYLAXIS:
There is a significant risk of femoral vein thrombosis in young and very sick children with DKA who have
femoral lines inserted. Therefore consideration should be given to anticoagulating these children with
low molecular weight heparin.
Children who are significantly hyperosmolar might also require anticoagulant prophylaxis (discuss with
your local consultant).
9
E.
CONTINUING MANAGEMENT:
•
•
•
•
•
Urinary catheterisation should be avoided but may be useful in the child with impaired
consciousness.
Documentation of fluid balance is of paramount importance. All urine needs to be measured
accurately (and tested for ketones if blood ketones are not being monitored). All fluid input must
be recorded (even oral fluids).
If a massive diuresis continues fluid input may need to be increased. If large volumes of gastric
aspirate continue, these will need to be replaced with 0.45% sodium chloride with Potassium
Chloride.
Check biochemistry, blood pH, and laboratory blood glucose 2 hours after the start of
resuscitation, and then at least 4 hourly. Review the fluid composition and rate according to each
set of electrolyte results.
If acidosis is not correcting, consider the following
o Insufficient insulin to switch off ketones
o Inadequate resuscitation
o Sepsis
o Hyperchloraemic acidosis
o Salicylate or other prescription or recreational drugs
Use near-patient ketone testing to confirm that ketone levels are falling adequately. If blood ketones
are not falling, then check infusion lines, the calculation and dose of insulin and consider giving more
insulin.
Consider sepsis, inadequate fluid input and other causes if sufficient insulin is being given.
Insulin management once ketoacidosis resolved –
Continue with IV fluids until the child is drinking well and able to tolerate food. Only change to
subcutaneous insulin once blood ketone levels are below 1.0 mmol/l, although urinary ketones may not
have disappeared completely.
Discontinue the insulin infusion 60 minutes (if using soluble or long-acting insulin) or 10 minutes (if using
Novorapid or Humalog) after the first subcutaneous injection to avoid rebound hyperglycaemia.
Subcutaneous insulin should be started according to local protocols for the child with newly diagnosed
diabetes, or the child should be started back onto their usual insulin regimen at an appropriate time
(discuss with senior staff).
F.
CEREBRAL OEDEMA:
The signs and symptoms of cerebral oedema include
•
•
•
•
•
headache & slowing of heart rate
change in neurological status (restlessness, irritability, increase drowsiness, incontinence)
specific neurological signs (e.g. cranial nerve palsies)
rising BP, decreased O2 saturation
abnormal posturing
More dramatic changes such as convulsions, papilloedema, and respiratory arrest are late signs
associated with extremely poor prognosis.
10
Management:
If cerebral oedema is suspected inform senior staff immediately.
The following measures should be taken immediately while arranging transfer to PICU –
•
•
•
•
•
•
•
•
G.
Exclude hypoglycaemia as a possible cause of any behaviour change
Give hypertonic (2.7%) sodium chloride (5mls/kg over 5-10 mins) or Mannitol 0.5-1.0g/kg stat
(=2.5-5 ml/kg Mannitol 20% over 20 minutes). This needs to be given as soon as possible if
warning signs occur (e.g. headache or pulse slowing).
Restrict IV fluids to ½ maintenance and replace deficit over 72 rather than 48 hours
Patients up to their 13th birthday will need to be moved to PICU (if not there already)
Discuss with PICU/ICU consultant. Do not intubate and ventilate until an experienced doctor is
available. Patients over 13 years should be transferred to ICU.
Once the patient is stable, exclude other diagnoses by CT scan – other intracerebral events may
occur (thromobosis, haemorrhage or infarction) and present similarly
A repeated dose of Mannitol may be required after 2 hours if no response
Document all events (with dates and times) very carefully in medical records
OTHER COMPLICATIONS:
•
•
•
Hypoglycaemia & hypokalaemia – avoid by careful monitoring and adjustment of infusion rates.
Consideration should be given to adding more glucose if BG falling quickly even if still above 4
mmol/l.
Systemic Infections – antibiotics are not given as a routine unless a severe bacterial infection is
suspected.
Aspiration pneumonia – avoid by nasogastric tube in vomiting child with impaired
consciousness.
Other associations with DKA require specific management:
Continuing abdominal pain is common and may be due to liver swelling, gastritis, bladder retention, or
ileus. However, beware of appendicitis and ask for a surgical opinion once DKA is stable. A raised
amylase is common in DKA.
Other problems are pneumothorax +/- pneumo-mediastinum, interstitial pulmonary oedema, unusual
infections (e.g. TB, fungal infections), hyperosmolar hyperglycaemia non-ketotic coma, and ketosis in
type 2 diabetes. Discuss these with the consultant on-call.
Equality, Human Rights and DDA
The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on
equality of opportunity or good relations for people within the equality and good relations categories.
Alternative formats
This document can be made available on request on disc, larger font, Braille, audio-cassette and in other
minority languages to meet the needs of those who are not fluent in English.
Sources of Advice in relation to this document
The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should
be contacted with regard to any queries on the content of this policy.
11
Appendix 1: Glasgow Coma Scale
Best Motor Response
1 = none
2 = extensor response to pain
3 = abnormal flexion to pain
4 = withdraws from pain
5 = localises pain
6 = responds to commands
Eye Opening
1 = none
2 = to pain
3 = to speech
4 = spontaneous
Best Verbal Response
1 = none
2 = incomprehensible sounds
3 = inappropriate words
4 = appropriate words but confused
5 = fully orientated
Maximum score 15, minimum score 3
Modification of verbal response score for younger children
2-5
< 2 years
1 = none
2 = grunts
3 = cries or screams
4 = monosyllables
5 = words of any sort
1 = none
2 = grunts
3 = inappropriate crying or unstimulated screaming
4 = cries only
5 = appropriate non-verbal responses (coos, smiles, cries)
12
Appendix 2:
Algorithm for the Management of Diabetic Ketoacidosis
in Children & Young People up to 18 Years
Clinical History
• polyuria
• polydipsia
• weight loss
• abdominal pain
• weakness
• vomiting
• confusion
Clinical Signs
• assess dehydration
• deep sighing respiration (Kussmaul)
• smell of ketones
• lethargy, drowsiness
Confirm Diagnosis
Diabetic Ketoacidosis
Call Senior Staff
Shock
Reduced peripheral pulse volume
Reduced conscious level
Coma
Resuscitation
• Airway +/- N/G tube
• Breathing (100% O2)
• Circulation (10ml/kg of
0.9% sodium chloride
repeated until
circulation restored,
max 3 doses)
No Improvement
Re-evaluate
• Fluid balance + IV- therapy
• If continued acidosis, may
require further resuscitation
fluid
• Check insulin dose correct
• Consider sepsis
Insulin
Start subcutaneous insulin then
stop intravenous insulin 1 hour
later (or 10 mins later if using
insulin analogues)
Dehydration > 5%
Clinically acidotic
Vomiting
Intravenous Therapy
• Calculate fluid requirements
• Correct over 48 hours
• 0.9% sodium chloride for at least 12 hours
• Add Potassium Chloride 20 mmol every
500ml
• Insulin 0.1U/kg/hour by infusion after first
hour of fluids
Observations
• hourly blood glucose
• neurological status at least hourly
• hourly fluid input:output
• electrolytes 2 hours after start of IVtherapy, then 4- hourly
• 1-2 hourly blood ketone levels
Biochemistry
• elevated blood glucose
(>11mmol/l)
• acidaemia (pH<7.3 and/or
Bicarbonate <15 mmol/l)
• ketones in urine or blood
• take blood also for
electrolytes, urea
• perform other
investigations if indicated
Dehydration < 5%
Clinically Well
Tolerating fluid orally
Therapy
• start with s.c. insulin
• give oral fluids
No Improvement
Blood ketones rising
Looks unwell
Starts vomiting
Neurological
deterioration warning
signs:
Headache, irritability,
slowing heart rate,
reduced conscious level,
specific signs raised
intra-cranial pressure
Blood glucose < 14 mmol/l
Exclude
Hypoglycaemia
Is it Cerebral oedema?
Intravenous therapy
• add 5% glucose to 0.9% sodium chloride
• change to 0.45% sodium chloride +
glucose 5% after 12 hours
• continue monitoring as above
• consider reducing insulin 0.05kg/hour, but
only when pH >7.3
Resolution of DKA
• clinically well, drinking well, tolerating food
• blood ketones < 1.0 mmol/l or pH normal
• urine ketones may still be positive
Management
• give 5 ml/kg 2.7%
sodium chloride or
mannitol 0.5-1.0 g/kg
• call senior staff
• restrict I.V. fluids by ½
• move to ITU
• CT scan when
stabilised
13
Appendix 3: Summary Guidelines for the Management of Diabetic Ketoacidosis
in Children & Young People up to 18 Years
Reference: BSPED recommended DKA Guidelines 2009 www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf
Always accept a referral of suspected DKA. Always consult with senior doctor on call.
call.
Diagnostic Criteria of DKA:
Blood glucose > 11 mmol/L; Venous pH < 7.3; Bicarbonate < 15 mmol/L
Emergency management in A&E –
•
ABC resuscitation & clinical assessment of dehydration (none,
(none, 3%, 5% or max 8%)
•
WEIGH the patient;
patient; calculate intravenous fluids / potassium / insulin (check all calculations with another staff member)
Infusion fluids
o
ALL fluids must be prescribed on FLUID PRESCRIPTION CHART.
o
If shocked, give 10ml/kg 0.9% sodium chloride IV bolus immediately.
o
Repeat if necessary to maximum of 30ml/kg.
o
Calculate fluid requirements:
Hourly Requirement = ( Maintenance + Deficit – resuscitation fluid already given ) / 48hrs
o
Calculate Deficit (ml) = % dehydration x body weight (kg) x 10
o
Calculate Maintenance requirements: weight 0-12.9kg
80ml/kg/24hrs
weight 13-19.9kg
65ml/kg/24hrs
weight 20-34.9kg
55ml/kg/24hrs
weight 35-59.9kg
45ml/kg/24hrs
weight >60kg (adult) 35ml/kg/24hrs
o
Total required volume of fluid should be given evenly over 48 hours
o
After bolus, use 0.9% sodium chloride with 20mmol KCl in 500ml for at least 12 hours.
o
If blood glucose falls to 14 mmol/L; switch to 500ml bag of 0.9% sodium chloride + 5% glucose + 20mmol KCl.
o
If serum sodium rises; switch to 500ml bag of 0.45% sodium chloride with 5% glucose and 20mmol KCl.
o
Check fluids on on-line calculator (www.bsped.org.uk/professional/guidelines/docs/DKACalculator.pdf)
and print copy for notes.
o
Check U&E’s 2 hrs after resuscitation and then at least 4 hourly.
Potassium
- Serum potassium is often normal or high initially but total body potassium is low.
- Once child has been resuscitated, commence potassium immediately with rehydration fluid unless anuria suspected.
- Anticipate fall in potassium once insulin is commenced.
- Ensure every 500ml bag fluid contains 20 mmol KCl (40 mmol per litre).
- Alter potassium replacements according to U&E’s; occasionally more than 40mmol/l potassium is required.
- Use cardiac monitor to observe T wave changes.
Insulin
o
o
o
o
o
o
o
o
o
o
o
o
o
Record insulin infusion on FLUID PRESCRIPTION CHART.
Check hourly blood glucose and record on DIABETIC CHART.
DO NOT start insulin until IV fluids have been running for at least 1 hour
DO NOT give an insulin bolus.
Make up IV insulin solution by adding 50 units (0.5ml) Actrapid® to 50ml 0.9% saline in a syringe pump.
Run IV insulin infusion at 0.1 units/kg/hour (0.1ml/kg/hour)
If blood glucose falls below 14mmol/l, change fluid to 500ml bag of 0.9% sodium chloride + 5% glucose + 20mmol KCl.
If blood glucose falls below 4mmol/l, give bolus 2ml/kg 10% glucose and increase glucose concentration of infusion to
500ml bags of 0.45% sodium chloride + 10% glucose + 20mmol KCl.
Decrease insulin infusion rate to 0.05 units/kg/hour when pH is above 7.3 and blood glucose is less than 14mmol/l.
Continue long acting insulin Lantus® or Levemir® throughout DKA treatment.
Patients on CSII pump therapy must stop the pump when starting DKA treatment.
If blood glucose or pH is not improving after 4-6 hours, consult senior medical staff and re-evaluate regimen.
Discontinue insulin infusion 10 mins after first s/c rapid-acting insulin injection (or after 60 mins if on soluble insulin).
Cerebral oedema
Cerebral oedema is a potentially serious complication of DKA and is mainly seen in children and young adults (clinically apparent in 1% of
cases). Clinical features usually develop 4 – 12 hours after the start of DKA treatment. Signs and symptoms include headache, slowing of
heart rate, rising BP, change in neurological status (fluctuating level of consciousness, abnormal response to pain, decerebrate posturing,
cranial nerve palsy, neurogenic respiratory pattern), incontinence. Convulsions and respiratory arrest are late signs associated with
extremely poor prognosis.
Management: Inform senior staff immediately.
•
•
•
•
Hypertonic (2.7%) sodium chloride 5mls/kg IV over 5-10 mins or Mannitol 0.5 – 1 g/kg IV stat; if no response, repeat after 2hrs.
Restrict IV fluids to ½ maintainence and replace deficit over 72 hrs.
Transfer to PICU for intensive monitoring and management.
Exclude other diagnosis by urgent CT scan.
Other measures
•
•
•
•
•
Accurately document all events with dates & times in medical records.
Consider urinary catheter only if impaired level of consciousness. Screen for infection and other precipitating factors.
Consider thromboprophylaxis if using femoral lines or if significantly hyperosmolar.
Bicarbonate should only be considered if pH<6.9 and in circulatory failure.
Treatment plan should be explained to young person and their parents.
14
Appendix 4: Algorithm for Referral, Admission and Management of Diabetic Ketoacidosis
in Children & Young People up to 18 Years according to age
Newly diagnosed Diabetic or known
diabetic patient presenting to:
•
•
•
GP
A&E Department
Community DSN
Age from birth up to 16th
birthday with DKA
(or other diabetes related
problem under 16 years)
Admit to Paediatric Ward
(Antrim or Causeway).
Manage under Paediatric
Guideline for DKA
Admit to Designated Adult Ward
under care of Medical
Consultant Physicians
Emergency
management
commenced
in A&E
Age over 16 years *
up to 18th birthday
in DKA
Antrim – Ward B2, or Ward B1 with
transfer to B2 when bed available.
Causeway – Medical 2 (or Cardiac
unit if monitoring required).
Manage under Paediatric
Guideline for DKA
Age 18 years and
over in DKA
Diabetic patient with DKA in:
•
•
•
Maternity/ Gynae ward
Theatre/ ICU
Day surgery
Admit to Adult medical Wards
(Antrim or Causeway)
Manage under Guideline for DKA
and HONK in adults (over 18yrs)
Age under 18 years
Follow Paediatric
Guideline for DKA
Age over 18 years
Follow Adult Guideline for
DKA and HONK in adults
*A small cohort of NAMED young people aged 16-17 years already attending Paediatric Diabetes Clinic
who have agreed direct consultation with Paediatric ward may be directly admitted
(NOT through A&E) if bed available. DKA managed under Paediatric Guideline.
15

Diabetic Ketoacidosis in Children and Young People up to 18 years NHSCT/10/358

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