Diabetic Ketoacidosis (DKA) in Pediatric Patient
Patient Presentation:
E.C. is a 15 year old female who presents to the ED at 21:00 with her mother. E.C. complains of vomiting on and off over the past 2 days, a headache, and “not feeling well.” She decided to come to the hospital when she started to have abdominal pain and was having trouble catching her breath. On initial assessment, E.C. is a thin girl who appears lethargic and to be having Kussmaul breathing. When the RN takes E.C.’s vital signs she notices E.C. to have a fruity odor to her breath. Her vital signs are: 36.5 degrees Celsius, HR 115, BP 90/50, RR 34, O2 saturation 94%. The RN instantly collects a finger stick blood glucose due to the fruity odor of E.C.’s breath to find a glucose level of >500 mg/dl. Other labs and cultures are collected and are notable for large urine ketones, a pH of 7.25 and HCO3 of 12. E.C. is started on IV hydration and is administered a dose of SQ Humalog®. Her glucose is checked again in 30 minutes and has dropped to 400 mg/dl. E.C. is transferred to the pediatric intensive care unit in order to be started on a continuous insulin drip and for continuous monitoring.
Differential Diagnoses
DKA in newly diagnosed type 1 diabetes mellitus, sepsis, dehydration, metabolic acidosis
Diagnosis
Labs on the unit include: Accu-chek® for glucose, CMP, CBC, ABG (or VBG if preferred), and blood cultures x2
Other tests on the unit include: continuous EKG, abdominal studies, urinalysis, urine culture, dipstick for ketones at bedside with each void, and urine pregnancy test
Most important results: glucose > 400, large ketones in urine, pH 7.3, bicarbonate 15, sodium 132, potassium 4.7, no abdominal/GI complications, and pregnancy test negative
Treatment:
The acute treatment goals for E.C. who is in DKA, are volume resuscitation, insulin therapy, monitoring serum markers for DKA, and prevention of complications such as cerebral edema. This is accomplished by starting IV fluids at maintenance plus replacement of 0.45% NaCl with added potassium, phosphate, and magnesium as needed over the next 36 – 48 hours. She is also started on a continuous insulin drip of 0.1 units/kg/hr. This rate is only changed when her acidosis is resolving and is not based on glucose levels. Glucose levels are checked every hour per protocol and dextrose is added to her IV fluids if her blood glucose decreases faster than 150 mg/dl/hr. The goal is to maintain blood glucose between 175 and 299 until acidosis resolves. BMP and VBG labs are checked every 2-4 hours per protocol. E.C. is made NPO and requires q1-2hr CNS checks to watch for cerebral edema.
Outcome:
E.C.’s acidosis resolves with no complications and she is diagnosed with type 1 diabetes mellitus that was most likely triggered by an infection. She is transitioned to SQ insulin and is transferred to the acute care unit where she and her mom will be educated on carbohydrate counting and insulin therapy. She will be followed by the endocrinology clinic.