Diabetic ketoacidosis dka is the most common hyperglycemic emergency in patients with diabetes. 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 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. 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. We sought to create and implement recommendations from an evidencebased pathway for hospital management of pediatric diabetic ketoacidosis dka and to sustain improvement. 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. Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the usa and. 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. Mild dka was previously defined in the international society for pediatric and adolescent diabetes guidelines as a ph of 7. Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the usa and worldwide. 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. The management of dka in children is summarized clinical features and diagnosis of diabetic ketoacidosis in children and adolescents view in chinese.
As a result, freefatty acids are used as the primary energy source. Dka red flags, risk factors, considerations for picu admission. The pediatric emergency care applied research network fluid fluid therapies under investigation in dka study is the. 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. The criteria for hyperglycemic hyperosmolar state hhs include. Management and treatment of pediatric type 1 diabetes. 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. Potential complications include cerebral edema, hypokalemia, hypoglycemia, and relapse. Many of the details about the risk factors as well as the mechanisms leading to dka related cerebral edema are not. Click to find referral pathways, guidelines and contact information. Peds morsels blog on cerebral edema in diabetic ketoacidosis. 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. Almost 1 in 100 children with dka will develop cerebral edema, which has a mortality rate of 2124%.
Describe the typical presentation of diabetic ketoacidosis. The lack of insulin prevents glucose from being used as an energy source. 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 usually occurs as a consequence of absolute or relative insulin deficiency that is accompanied by an increase in counter. Diabetic ketoacidosis and hyperglycemic hyperosmolar state asped. 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. Pdf the management of diabetic ketoacidosis in children. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Criteria and overview pathophysiology of dka explanation of evidence ratings summary of version changes inclusion criteria dka is defined as need all 3 criteria. Emergency department management clinical practice guideline cpg protocol approved by. Does protocol implementation decrease length of stay in. Diabetic ketoacidosis dka represents a profound insulinde. 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. Cerebral edema may be present at the time of initial assessment or.
Pathophysiology diabetic ketoacidosis dka is a complex disordered metabolic state characterised by hyperglycaemia, acidosis, and ketonaemia. The dka medical protocol can also be downloaded in fillable pdf format. 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. Ada1,chi management and treatment of pediatric type 1 diabetes care process model february 2017.
Diabetes type 1, with dka clinical pathway emergency. Pediatric dka protocol this protocol is intended as a guide individual patient modifications may be necessary. Diabetic ketoacidosis, pediatric emergency and inpatient. Dka at diagnosis is more common in children dka represents a profound insulindeficient state characterized by hyperglycemia 200 mgdl 11. Patients identified with diabetic ketoacidosis during their hospital stay background definitions diabetic ketoacidosis dka is a lifethreatening condition. 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 is characterized by a serum glucose level greater than 250 mg per dl, a ph less than 7. 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. However, each patient should be considered as an individual in the context of their condition and other medication and therefore the readers discretion is. A subscription is required to access all the content in best practice. 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.
Diabetic ketoacidosis dka care guidelines emergency. The biochemical criteria for the diagnosis of diabetic ketoacidosis dka are. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. The management of diabetic ketoacidosis in children.
In new onset diabetes, dka is frequently the consequence of a delay in diagnosis e. Click to learn how to make a referral and who to contact locally to get your patient connected to these services. Pediatric diabetic ketoacidosis, fluid therapy, and. 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. Treatment of diabetic ketoacidosis with subcutaneous insulin. Pediatric diabetic ketoacidosis, fluid therapy and cerebral. 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. The bc childrens hospital diabetic ketoacidosis dka protocol has now been. Wrnmmcb pediatric diabetic ketoacidosis clinical practice guideline 1. Dka is most commonly seen in patients with type 1 diabetes since the disease is defined by insulin deficiency. The authors created a working definition that incorporates both biochemical and social factors. Completing more than 20,000 ambulatory encounters per year, bdc is the largest outpatient. Unc pediatric dka guidelines this is a general guideline and does not represent a professional care standard governing providers obligations to patients. Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the united states and worldwide.
Wrnmmcb pediatric diabetic ketoacidosis clinical practice. Pediatric diabetic ketoacidosis dka treatment guide childrens. Dka treatment protocol barbara davis center for childhood. The clinical guidelines and references provided on this website are developed by the department of emergency medicine at maine medical center. Diabetes type 1, with dka clinical pathway emergency childrens hospital of philadelphia. Pediatric diabetic ketoacidosis dka treatment guide.
This is a quality improvement document and should not be part of the patients medical record. Diabetic ketoacidosis dka is biochemically defined as a venous ph 200 mgdl 11 mmoll together with ketonemia, glucosuria, and ketonuria. Our goal was to describe our longterm experience in the. The biochemical criteria for the diagnosis of diabetic ketoacidosis. Diabetic ketoacidosis dka is the metabolic abnormality of type 1 diabetes. The proper management of dka requires intense monitoring and clear understanding of pathophysiology related to it. Ua, cbc, serum osm, hgba1c, lft, mg, phos, amylase, lipase do not delay treatment while obtaining labs abcs, gcs. Dka sample physician order sheet dka glucose, fluid and insulin management dka nursing protocol including the twobag method dka recipes for making solutions. Dka frequency at the time of diagnosis of pediatric diabetes is 10%70%, varying with the.
Dka also can occur in children with type 2 diabetes. Diabetic ketoacidosis american academy of pediatrics. Descriptionetiology lesson quick diabetic ketoacidosis in. Choose one of the access methods below or take a look at our subscribe or free trial options. This is a quality improvement document and should not. Outpatient or inpatient care child with new dm diagnosis. Diabetic ketoacidosis dka childrens hospital colorado. Barbara davis center serves more than 90% of colorado children diagnosed with type 1 diabetes. The most feared complication in the clinical course of children with diabetic ketoacidosis dka is the development of cerebral edema. Off algorithm, look for alternative diagnosis initiate dka powerplan and send labs. On page 2 of dka critical care guidelines cerebral edema treatment give mannitol 0.
No protocol for dka has been shown to eliminate the risk of cerebral oedema and this guideline is based on. Diabetic ketoacidosis dka in children and adolescents has a mortality rate of 1% to 2%. 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. Dka development is intrinsically tied in with dysregulation of these systems. If protocol contraindicated or not ordered, notify physician.
It is intended to be a reference for clinicians caring. 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. A consensus statement from the international society for pediatric and adolescent. It reflects our expert opinion and is not necessarily applicable to all institutions. Consumption of freefatty acids leads the formation of ketoacids and precipitates a. Enhance resident management of pediatric dka and improve patient safety. Diabetic ketoacidosis dka critical care guideline two bag. Morales, md associate professor of pediatrics barnstable brown diabetes center uk healthcare june 15, 2019 faculty disclosure no relevant financial relationships to disclose. Divisions of pediatric emergency medicine and endocrinology date of approval.
Paediatric management of diabetic ketoacidosis dka squarespace. Red deer regional hospital diabetic ketoacidosis dka pediatric protocol. 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 management of diabetic ketoacidosis in children ncbi. Management of diabetic ketoacidosis in children and.
Prebreakfast administer both glargine and aspart dose according to premeal aspart order set. Dka frequency at the time of diagnosis of pediatric diabetes is. 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. Clinical guideline childrens hospital of richmond at vcu. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury. Treatment of diabetic ketoacidosis with subcutaneous. Correct ketosis and acidosis with continuous insulin. Research design and methods a total of 45 consecutive patients admitted with dka. 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. Dka that ensues is an example of a superfasted state. Treatment of pediatric diabetic ketoacidosis in canada. Ispad clinical practice consensus guidelines 2014 compendium.
Improving care for pediatric diabetic ketoacidosis. Pediatric diabetic ketoacidosis and hyperglycemic hyperosmolar state. 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. Diabetic ketoacidosis, pediatric emergency and inpatient v 1. Division of critical care, department of pediatrics, childrens hospital of wisconsinmedical college of wisconsin, milwaukee, wi abbreviations. Children were randomly assigned to one of four treatment groups in a 2by2 factorial design 0. Pdf management of diabetic ketoacidosis in children and.
Reevaluate appropriateness of replacement fluid type frequently. Diabetic ketoacidosis dka critical care guideline two. Following the publication of the pekarn dka fluid trial new engl j med 2018. For pediatric dka sites follow algorithm below for two plus. This version autocalculates the fluid rates and has some popup screens to guide in the clinical evaluation of children presenting with dka. Emergency care applied research network pecarn dka fluid study group. Those with severe dka have a much higher mortality and risk of complications.
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