A 7 year old male who weighs 50 pounds presents to the ED with 2 day history of abdominal pain, no fever, had URI 2 weeks ago. Patient has been drinking well and has been waking at night to void. On physical exam, cap refill is delayed and there is a significant weight change from an appointment 2 weeks ago. Random glucose is 600 mg/dL and Urinalysis reveals elevated glucose and ketones in urine.
What is the Dx?
What is the initial treatment you would give? (3 things)
- Dx: Diabetic Ketoacidosis
- Place IV and give:
1. 20ml/kg of 0.9NS bolus admin (stabilize CV status)
2. Administer 0.1 units of Insulin per hour
3. Give potassium infusion
Following initial treatment treatment of DKA with bolus fluid, insulin, and potassium, what molecule should you be concerned about replenishing in the patient?
When this molecule drops below _____ , you should start infusion to keep the patient stable.
- blood glucose levels
- 200 mg/dL
What lab tests should you obtain immediately after initial treatment of a pediatric patient with DKA? (x3)
- BMP (Na, K, Cl, BUN, Cr, Gluc)
- Blood gas (VBG more gentle than ABG)
Maintenance fluids by weight:
1. Per 24 hours?
2. Per 1 hour?
1. first 10 kg = kg x 100 ml/kg/day, next 10 kg = kg x 50 ml/kg/day, kg above 20 kg = kg x 20 ml/kg/day
2. Hourly rate = 4 / 2 / 1 ml/kg/hour (same pattern)
You should stop IV insulin and fluids when:
1. Anion gap is less than _______
2. Venous pH is greater than ______ or HCO3 is greater than ______
3. When glucose is less than _______
4. when patient can tolerate _________
2. 7.3, 15
4. oral intake
Failure of Na+ to improve after treatment may be an early sign of risk for what?
In DKA there is total body depletion.
When should you not administer Insulin in the treatment of a DKA patient?
- If the patient is hyperkalemic, do no administer insulin until K+ is in normal range
- Insulin drives K+ intracellularly (which causes problems)
1. What will hypokalemia show?
2. what will hyperkalemia show?
1. hypokalemia = flat T waves, U waves, prolonged PR interval
2. hyperkalemia will cause peaked T waves
Rate: Ventricular rate 81
Rhythm: Normal Sinus Rhythm
Axis: Normal Axis
Final ECG Interpretation: U waves consistent with hypokalemia