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sweet & sour…

February 3, 2013 By Christopher Partyka Leave a Comment

The case.

A 7 year old boy presents to your ED with a 3-4 day history of fevers, nausea and vomiting. There is some associated non-specific abdominal pain. He has a history of Type 1 Diabetes Mellitus. His blood glucose at triage is reading ‘HI’ and his finger-prick ketones are 6.4 mmol/L. He is therefore taken through to your resus bay, where you achieve IV access and get the following set of results…

BloodGas

EUCs

 

How do you approach this child ?

Well, there are no hidden tricks with this case. This is not a fancy diagnosis, rather a very common one. I feel that if you are in a department that sees children, then you need to know Paediatric DKA back to front & be able to manage it with a certain level of finesse, particularly as there is certainly the potential to do more harm than good.

What are your principles of management?

Management of Paediatric DKA.

I wanted to use this case as a vignette to bring the following paper to your attention….

ISPADpaper

To my knowledge it is the most concise paper that summarises the management of Paediatric DKA. Below are what I consider the pertinent points to take from this guideline…

Diagnosis:

    • * Hyperglycaemia 
           - Blood glucose > 11mmol/L (200mg/dL)
      * Venous pH < 7.3 or HCO3 < 15mmol/L
      * Ketonaemia / Ketonuria.

Severity:

    • * Mild
           - pH < 7.3  or  HCO3 < 15 mmol/L
      * Moderate
           - pH < 7.2  or  HCO3 < 10 mmol/L
      * Severe  
           - pH < 7.1  or  HCO3 < 5 mmol/L

Goals of Therapy:

    • * Correct dehydration.
      * Correct acidosis & reverse ketosis.
      * Restore blood glucose to near normal.
      * Avoid complications of therapy.
      * Identify & treat any precipitating causes.

Fluid Management:

    • * Severe volume depletion w/out shock.
           - Volume resuscitation begins immediately w/ 0.9% saline.
           - Aim for 10mL/kg/hr over 1-2 hours
                ~ repeat if necessary.
           - Do not exceed 30mL/kg in first 4 hours.
      
      * DKA w/ shock (rare).
           - 20mL/kg bolus (0.9% Saline or Hartman's) 
           - reassess after each bolus
           - don't forget the intraosseous route !
      
      * Subsequent fluid management (deficit replacement).
           - 0.9% Saline or Hartman's for at least 4-6 hours.
                ~ Thereafter; tonicity > 0.45% (w/ added K+)
           - Calculate fluid deficit (ie. 5 vs 7 vs 10% dehydration).
                ~ Rehydrate evenly over 48 hours
                ~ Avoid rates of > 1.5-2x usual daily maintenance requirements.
                ~ click here for fluid calculation example
           - No need to add urinary losses to fluid calculations.
           - Sodium content may need to be increased 
             (if Na+ not increasing w/ appropriate therapy).

Insulin Therapy:

    • * Start insulin infusion 1-2 hours after commencing fluid replacement.
           - ie. after initial volume expansion.
      * Dose = 0.1 units / kg / hour (via infusion).
           - reduce to 0.05 units/kg/hr in those w/ exquisite insulin sensitivity.
           - do not use boluses !!
      * Continue insulin until DKA resolves [ Target BSL ~ 11mmol/L ].
           - ie. pH > 7.3, HCO3 > 15 mmol/ or anion gap is closed.
      * Add 5% Dextrose to IV fluid when glucose ~ 14-17mmol/L
           - consider adding earlier w/ rapid glucose drop (>5mmol/hr).
           - up to 10-12.5% may be required to correct acidosis.

Potassium Replacement:

    • * Children w/ DKA have total body deficits of up to 3-6 mmol/kg.
      * Replacement is required regardless of serum K+ concentration.
           - If hypokalaemic;
                ~ start K+ replacement w/ initial volume expansions.
                ~ concentration of 20mmol/L should be used.
           - If normal K+;
                ~ start K+ replacement after expansion, before insulin therapy.
           - If hyperkalaemic;
                ~ defer K+ replacement until urine output is documented.
      
      * Maintenance therapy;
           - Potassium concentration of 40mmol/L.
      * Maximum replacement is ~ 0.5mmol/kg/hr.
      

Phosphate Replacement:

    • * No clinical benefit from routine replacement.
      * Severe hypophosphataemia w/ unexplained weakness should be treated.
      * Potassium phosphate can be used with KCl to replace both.
           - Beware inducing hypocalcaemia.

Acidosis:

    • * Severe acidosis is reversible by fluid & insulin therapy.
           - Insulin stops further ketoacid production & generates bicarbonate.
      * No clinical benefit from bicarbonate administration.
           - May cause paradoxical CNS acidosis.
      * Consider bicarbonate use in;
           - severe acidosis (pH < 6.9) w/ decreased cardiac contractility 
             & vasodilatation 
           - life threatening hyperkalaemia.

Cerebral Oedema:

    • * Responsible for 60-90% of all DKA-related deaths.
      * Incidence ~ 0.5-0.9% of DKA cases.
      * Mortality ~ 21-24%.
      
      * Risk Factors:
           - younger age / New onset diabetes / longer duration of symptoms
           - greater hypocapnia (adjusted for severity of acidosis)
           - more severe acidosis
           - increased serum urea
           - bicarbonate therapy (to correct acidosis)
           - greater volumes of fluid given in first 4 hours
           - attenuated rise in serum sodium concentration (despite therapy)
           - administration of insulin in first hour of fluid therapy
      
      * Signs & Symptoms:
           - Headache / progressive bradycardia or hypertension
           - Altered neurological status
                ~ restlessness
                ~ irritability
                ~ drowsiness
                ~ incontinence 
           - Focal neurological signs (eg. cranial nerve palsies)
           - Decreased oxygen saturations.
      
      * Treatment:
           - Elevate head of bed
           - Reduce IV fluids to 1/3 the rate
           - Mannitol:
                ~ 0.5-1.0 grams/kg over 20 minutes.
                ~ repeat if no response in 30-120 minutes.
           - Hypertonic (3%) saline.
                ~ an alternative to mannitol
                ~ 5-10mL/kg over 30 minutes.
           - Intubation. Avoid aggressive hyperventilation.
           - CNS imaging (CT-Brain); 
                ~ confirming diagnosis/assessing for alternate diagnoses.

References

Reference.

  1. Wolfsdorf, J. et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatric Diabetes. 2009. 10 Suppl 12: 118–133.

 

Filed Under: Acid-Base, Endocrine, Paediatrics Tagged With: diabetes, diabetic ketoacidosis, DKA, endocrinology, insulin, ketones, paediatrics, pediatrics

a twisting tale…

January 26, 2013 By Christopher Partyka Leave a Comment

the case.

It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem to ever get any shorter….

At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…

She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).

You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.

Despite further boluses of morphine, she continues to vomit and complain of severe pain…

…so you order a plain X-ray

IMG_1870

The Questions

What’s going on here ?
What are you going to do now ??

The Discussion

Evidence based thinking

Upon reviewing the film, my immediate concerns was of a closed-loop obstruction. On further questioning, the young patient had not opened her bowels for 2 days, and had not passed flatus for at least 24 hours. Our surgical registrar agreed to review the patient….

Paediatric Bowel Obstruction.

The symptoms are generally non-specific with irritability, persistent vomiting, abdominal pain and distention. There are many different causes and pathological processes behind paediatric bowel obstruction. They include the following….

Congenital Causes.

      • atresia (duodenum, jejunum, oesophagus)
      • pyloric stenosis
      • meconium ileus
      • aganglionic megacolon
      • malrotation
      • constriction bands
      • intraabdominal hernias

Intussusceptions.

      • Ages 3 months – 6 years.
      • Requires a lead point (only found in 2-8% of cases)
          • Viral illness / gastroenteritis / rotavirus –> lymphoid tissue swelling.
          • Meckel’s
          • Peutz-Jaghers Syndrome

Incarcerated Hernias.

      • Umbilical – very common. rarely incarcerate.
      • Inguinal – very common. 10x more common in boys. more common in prematurity.
      • Femoral – rare in children. females >> males.

Malrotation with midgut volvulus.

      • 1 in 500 infants.
      • Error of rotation around the SMA axis.

Postoperative Adhesions.

      • Responsible for 3-8% of intestinal obstructions in infants/children.
      • Incidence lower after laparoscopic procedures than after laparotomy.

Annular Pancreas.

      • Rare congenital anomaly
      • Pancreatic tissue fully encircles the 2nd part of duodenum (leaving a non-distensible ring and a functional stenosis).

the conclusion.

The surgical registrar is agreeable with suspicion of bowel obstruction & the patient is consented for a diagnostic laparotomy. As the patient rolls off to theatre, I go home to bed….

My phone beeps midway through the day and I receive the following picture in an MMS.

IMG_1876

Following surgical release, her bowel immediately reperfused & remained viable. She is discharged home 4 days later without complication…

my thoughts…

In the ED, we are often faced with a never-ending ‘To-Do’ list and are asked to meet time-lines for decisions and dispositions that seem to be getting shorter & shorter…

For me, this case is a reminder that if your patient:

  1. isn’t following the expected path of the proposed diagnosis
  2. isn’t getting better with the therapy instituted to date.

Take a step back and start from scratch, reviewing the case from the very beginning…

 

Filed Under: Paediatrics, Radiology, Reflection, Surgery Tagged With: abdominal pain, adhesions, bowel obstruction, paediatrics, pediatrics, vomiting

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