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Morning Report

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by

Norah Emara

on 12 June 2014

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Transcript of Morning Report

Morning Report
Norah Emara, MD

Exam/Labs
Goals of DKA Management
DKA Complications
Cerebral Edema
Electrolyte Abnormalities
HypoKalemia
Hypophosphatemia
Hypoglycemia
Thrombosis
Infection
Recap
1. Identify DKA by focused history/exam
2. Obtain pertinent baseline labs
Blood gas, CHEM-10, U/A
3. Stabilize patient keeping considerations unique to DKA in mind
4. Fluid resuscitate only if indicated for hemodynamic instability
Calculate replacement fluids
5. Correct HYPERGLYCEMIA to address acidosis
insulin gtt
6. Anticipate complications and be prepared
electrolyte derangements
cerebral edema


Cape Cod Hospital
calls for transport...

"10 yo M with respiratory distress and abdominal pain..."
Your fab transport team
calls you on arrival...
"This kid's working really hard..."
What exam findings do you ask for?
Focus on transport
Exam
Labs/Imaging
DS 482

ABG: 7.05/12/93/5

CHEM: 131/3.3/106/4/12/0.9<478

Ketones 10.2 Serum Osm 315

CBC 22.5>11/44<482

U/A: 3+ glucose, 3+ ketones, LE+, Nitrite +

Urine Cx, Blood Cx Pending
VS
Airway
Breathing
Circulation
Disability (neuro)
Pertinent +



Diagnosis...
Diabetic Ketoacidosis
DKA is defined as:
(1) Hyperglycemia > 200 mg/dL AND
(2) Ketonemia/ketonuria AND
(3) Venous pH < 7.3 or HCO3 < 15
Historical Features
Polyuria/Polydipsia
Enuresis/Nocturia
Wt loss
Abdominal pain
N/V
HA
Confusion
Candida Infections
Clinical Signs
Dehydration
Kussmaul breathing
Lethargy
Vomiting
Abdominal tenderness
MS changes
Smell of Ketones (Juicy Fruit)
(1) correct dehydration
*carefully!!!!!
(2) correct acidosis and reverse ketosis
(3) normalize blood glucose
(4) minimize risk of DKA complications
(5) identify and treat any precipitating event
(6) provide diabetes education for DKA prevention
Fluids
Glucose Regulation
and Insulin
Electrolytes
Replace Water and Salt deficit

Start with 10-20 ml/kg NS
DON'T OVERDO IT
Volume expand only if needed for hemodynamic stability

Calculate Fluid deficit
ex. 25 kg; moderate dehydration

2 Bag Method
Titration based on glucose

Start Regular Insulin gtt AFTER starting fluid replacement
"Low dose" Insulin gtt
0.05-0.1 units/kg/hr
Monitor rate of glucose decrease
DS qhr
Goals: Drop glucose by 50-100/hr

Labs and Monitoring
Neuro Checks qhr
DS qhr
More often when changes are being made
Serum Ketone q2h
Chemistry, VBG q2-4h
Cerebral Edema
Cerebral Edema Management
Ensure adequate circulation
Reduce rate of fluids if possible
Ensure airway
Hyperventilate if needed
Avoid intubation
Elevate HOB, keep head midline
Osmotic Agents
Mannitol: 1 g/kg IV over 20 mins
3% saline: 3-6 ml/kg IV
3% gtt with Na target 150-160
CT head when stable
Electrolytes
HypoKalemia
Falsely elevated at diagnosis
K replacement
40 meq/L starting dose
Hypoglycemia
Never shut off insulin if DKA not yet corrected
Titrate glucose w/ 2 bag method
Hypophophatemia
Renal losses
Replace with KPhos
Other Complications
Thrombosis
DKA is a hypercoagulable state
stasis/immobility
endothelial damage
Dehydration contributes, too
Avoid CVCs if possible
Infection
Often antecedant to DKA
Maintain high index of suspicion
Test/Tx per findings
Hence the infx w/u at presentation
Pseudohyponatremia: correct for hyperglycemia

Hypokalemia: replacement usually starts at time of insulin infusion OR when patient has had first UOP
~ 40 meq/L: Kphos, Kace

Bicarb administration is controversial and not indicated due to poorer outcomes

Monitor Serum Osm closely
rapid and significant drops can
lead to cerebral edema
NEVER discontinue Insulin gtt before anion gap closed
-May titrate down insulin
if needed
References
1. Floating Hospital for Children DKA Protocol
2. Seattle Children's Hospital Diabetic Ketoacidosis Pathway
3. Cooke D, Plotnick L. Management of Diabetic Ketoacidosis in Children and Adolescents. Pediatrics in Review, 2008 (29); 431-439
Pertinent HPI
Divide into level specific groups
Interns: 5 Questions
MS: 7 questions
AG=Na-(Cl+HCO3)
Corrected Na:
Na+[(BG-100)]/100
Calculated Osm:
2(Na) + Glu/18 + BUN/2.8
GCS
Full transcript