Paediatric DKA Guideline 2015 – What’s new?

PEMgeek3I put up the link to the revised BSPED DKA guideline recently, so I thought I’d follow up with this post to explain exactly what all the changes are. Most of them relate to fluid management and seem to be geared towards making sure we don’t end up overshooting with rehydration and putting kids in danger of cerebral oedema – seems pretty reasonable ūüėČ

In DKA, there is a hypertonic state due to the massively elevated plasma glucose concentration. The theory is, that in order to avoid osmotic losses, brain cells produce osmotically active substances to counter the extra osmolality of the hypertonic plasma. If the plasma glucose concentration is corrected TOO FAST, not giving time for the osmotically active substances in the brain to dissipate, fluid gets drawn into the cells causing cerebral oedema.

pancreas

BSPED highlighted seven major updates – mostly about fluid management –¬†that I’ll explain briefly. The full guideline runs to 92 pages so probably not one to sit down to unless you have insomnia.

¬†¬†¬†¬†¬†¬†¬†¬†¬† 1. ‘Change in degree of dehydration used to calculate fluids’ (5% deficit for moderate, 10% deficit for severe DKA, based on pH)

According to¬†the 2015 guideline, pH below 7.1 = severe DKA. Kids with pH above 7.1 (mild to moderate DKA) should be assumed to be 5% dehydrated, and kids with pH below 7.1 should be assumed to be 10% dehydrated. This is a change from the previous 2009 guideline, which said that you shouldn’t ever assume more than 8% dehydration.

Now worried about over-hydrating these patients? Read on, as most of the other changes are all about controlling the total amount of fluids given.

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¬†¬†¬†¬†¬†¬†¬†¬† 2. ‘De-emphasise sodium chloride bolus at start of treatment (apart from sickest children)’

Giving fluid boluses to children with mild to moderate DKA (pH above 7.1) is NO LONGER recommended. This reduces the risk of causing cerebral oedema by rehydrating too fast during initial management.

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¬†¬†¬†¬†¬†¬†¬†¬† 3. ‘No more than one 10ml/kg fluid bolus to be given without discussion with senior doctor’

You should only be giving one fluid bolus to a child in severe DKA (below 7.1 pH) – after this, any further fluid boluses need to be discussed with a senior paediatrician.

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¬†¬†¬†¬†¬†¬†¬† 4. ‘Further reduction of maintenance fluid rates, and simpler calculation of fluids’

The ‘reduced volume’ rules are these:

Weight under 10kg: fluids at 2ml/kg/hour

Weight between 10-40kg: 1ml/kg/hour

Weight above 40kg: fixed volume of 40ml/hour

So much simpler than the last guideline – my number-phobic brain approves. Cheers BSPED

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¬†¬†¬†¬†¬†¬†¬†¬†¬† 5. ‘No longer to subtract any fluid boluses given up to 20ml/kg from the fluid calculation’

If you’re following points 2) and 3), the kid probably won’t have had over 20ml/kg in the way of fluid boluses anyway.

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¬†¬†¬†¬†¬†¬†¬†¬† 6. ‘Continuation of 0.9% NaCl instead of changing to 0.45% NaCl’

The 2009 guideline recommended changing to 0.45% NaCl for intermediate to late rehydration. New guideline makes no mention of 0.45% NaCl – just continue with your 0.9% for the 48h rehydration period. All fluids (apart from initial bolus, if given) should have 40mmol/L potassium chloride (unless the kid is in renal failure).

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¬†¬†¬†¬† ¬† ¬† 7. ‘Option of using 0.05 units/kg/h OR 0.1 units/kg/h of insulin’

I thought this one was fairly well accepted already (although in hindsight I used to work in a tertiary paediatric diabetes centre so they may have been ahead of the curve). Gradual correction of blood glucose is the name of the game. Also, the full guideline reiterates NOT to use insulin boluses.

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OTHER USEFUL SNIPPETS (that lots of places already do anyway, but now they’re in the guideline so no excuses!)

  • Record plasma bicarbonate on presentation
  • Record child’s weight on presentation
  • Do not give extra fluid to compensate for urine losses
  • Replace the fluid deficit evenly over 48 hours
  • If there is persisting ketosis despite a blood sugar under 6, increase the glucose concentration in the IV fluid¬†and CONTINUE the insulin infusion – at least 0.05 units/kg/hour
  • Continuous ECG whilst in DKA and on continuous fluids, to monitor for effects of hypokalaemia

Use the BSPED .pdf calculator! Seriously one of the most useful clinical management tools out there.

dka2

***Disclaimer Рas always please consume FOAMed responsibly, follow the guideline directly from the BSPED site or your local protocols when caring for a sick child***

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