Paediatric Diabetic Ketoacidosis

Basic Science and Pathophysiology

3 Topics

Pathophysiology of DKA

Clinical Manifestations

Clinical Assessment and Risk Stratification

4 Topics

Initial Emergency Assessment

Full clinical assessment

Observations & monitoring

7 Topics

Volume of fluid required

Type of fluid required

Other Considerations

When to Convert to SC Insulin

Key Learning Points

1 Topic

Paediatric Diabetic Ketoacidosis

Paediatric Diabetic Ketoacidosis

Paediatric Diabetic Ketoacidosis Paediatric Diabetic Ketoacidosis

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Question 1 of 10

1. Question
1 point(s)
A 6-year-old boy (20 kg) is admitted to the emergency department (ED) with suspected DKA. He is vomiting and clinically dehydrated.

Which of the following best fits the biochemical definition of DKA?
- Blood pH <7.3, glucose >7 mmol/L and ketosis
- Blood pH <7.0, glucose >7 mmol/L and ketosis
- Blood pH <7.3, glucose >11 mmol/L and ketosis
- Blood pH <7.0, glucose >11 mmol/L and ketosis
- Blood pH <7.3, glucose >30 mmol/L and ketosis
Question 2 of 10

2. Question
1 point(s)
A 6-year-old boy (20 kg) is admitted to the ED with suspected DKA. He is vomiting and clinically dehydrated.

What are the initial management priorities for this patient within the ED?
- Airway, breathing, circulation
- Identify and treat the presence of shock with a 20 ml/kg bolus of 0.9% saline
- Commencing subcutaneous (SC) insulin, IV fluids and potassium as soon as possible
- Commencing intravenous (IV) insulin, fluids and potassium as soon as possible
- Refer to the paediatric team for further management
Question 3 of 10

3. Question
1 point(s)
A 6-year-old boy (20 kg) is admitted to the ED with suspected DKA. He is vomiting and clinically dehydrated.

On examination he localises to pain, is opening his eyes spontaneously and is confused. He has a heart rate of 140 beats/min, capillary refill time of 3-4 seconds, reasonable volume peripheral pulses and blood pressure within normal limits.

What is his Glasgow Coma Score (GCS)?
- 15
- 14
- 13
- 9
- 3
Question 4 of 10

4. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

On examination he localises to pain, is opening his eyes spontaneously & is confused. He has a heart rate of 140 beats/min, capillary refill time of 4 seconds, reasonable volume peripheral pulses & blood pressure within normal limits.

What is the appropriate initial fluid resuscitation?
- 10ml/kg 0.9% saline stat
- 20ml/kg 0.9% saline stat
- No fluid bolus indicated
- 5ml/kg 0.9% saline aliquots titrated to response
- 1L bag of Hartmann’s over an hour
Question 5 of 10

5. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

He responds well to the fluid bolus & is no longer clinically shocked. His GCS also returns to normal.

After initial resuscitation what are the fundamental principles of DKA management?
- Further treatment can wait until he is admitted to the paediatric ward
- IV insulin, fluids & potassium as soon as possible, started at the same time
- SC insulin & oral fluids
- IV fluids, insulin & potassium. Insulin should be given at least one hour after fluids have been started.
- IV fluids & insulin. Potassium should not be given until serum levels are confirmed on laboratory U&Es.
Question 6 of 10

6. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

After the fluid bolus you are asked to write up the on-going fluids requirement. His initial blood gas shows a pH of 6.9.

What are his on-going requirement over the next 48 hours (ml/hour)?
- 58ml/hour
- 96ml/hour
- 66ml/hour
- 92ml/hour
- 100ml/hour
Question 7 of 10

7. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

After the fluid bolus you are asked to write up the on-going fluids requirement. His initial blood gas shows a pH of 6.9. He has passed urine.

What type of fluid would be the most appropriate in this case?
- 500ml bag 0f 0.9% saline
- 500ml bag of 0.9% saline with 20mmol KCl
- 1L bag of 0.9% saline with 20mmol KCl
- 500ml bag of 0.45% saline with 20mmol KCl
- 1L bag of Hartmann’s (i.e. Ringer’s lactate)
Question 8 of 10

8. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

A 500ml bag of 0.9% saline with 20mmol KCl is started as part of the initial fluid management.

What is the appropriate management with regards to commencing insulin?
- Give 6 units SC insulin
- Give 10 units SC insulin
- Start an IV insulin infusion (50ml 0.9% saline with 50 units Actrapid®) at 2ml/hour at the same time as starting IV fluids
- Start an IV insulin infusion (50ml 0.9% saline with 50 units Actrapid®) at 2ml/hour at least one hour after IV fluids
- Start an IV insulin infusion (50ml 0.9% saline with 25 units Actrapid®) at 2ml/hour at least one hour after commencing IV fluids
Question 9 of 10

9. Question
1 point(s)
A 6-year-old boy (20kg) is admitted to the ED with suspected DKA. He is vomiting & clinically dehydrated.

2 hours after starting fluids & insulin his repeat bloods reveal pH 7.0, glucose 12, ketones 4.0 & potassium 4.0.

What is the appropriate management at this time?
- Add 5% glucose to the fluids & maintain the insulin infusion at 0.1 units/kg/hour
- Add 5% glucose to the fluids & maintain the insulin infusion at 0.05 units/kg/hour
- Continue 0.9% saline with 20mmol KCl but stop insulin infusion
- Add 10% glucose to the fluids & maintain the insulin infusion at 0.1 units/kg/hour
- Add 10% glucose to the fluids & maintain the insulin infusion at 0.05 units/kg/hour
Question 10 of 10

10. Question
1 point(s)
A 6-year-old boy (20 kg) is admitted to the ED with suspected DKA. He is vomiting and clinically dehydrated.

Four hours after starting IV fluids and insulin he complains of a headache and appears agitated. The nurses complain he is keeping the other patients awake.

What is the appropriate management at this time?
- Give paracetamol and reassess in one hour
- Sedate the patient with benzodiazepines
- Check for hypoglycaemia, restrict fluids and discuss with a PICU consultant. Treatment with mannitol or hypertonic saline can wait until the patient is transferred
- Check for hypoglycaemia, restrict fluids and discuss with a PICU consultant. Mannitol or hypertonic saline should be administered urgently
- Arrange an urgent CT head

1 Comment

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ul haqm9568 January 24, 2018 at 3:25 pm

very useful

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