醫學筆記匯整 ED Notes

BSPED guideline 2015 何家瑋

- Conscious Level : GCS
- Cerebral edema : headache, irritability, slowing pulse,
   rising BP, reducing GCS (papilloedema is a late sign)
- Infection
- Ileus
- Weigh the child
 

Initial fluid bolus : 
 - Do not routinely give an IVF bolus to children and young people with severe DKA (pH<7.1). 
 - Only if Shocked (poor peripheral pulses, poor capillary filling with tachycardia, and/or hypotension) 
   Give 10 ml/kg 0.9% NS as a bolus. 

 - Use 0.9% NaCl with 20 mmol KCl in 500 ml
   until blood glucose levels are less than ≈250mg/dL

Blood glucose, ketones
BUN, electrolytes, ABG
+/− full blood count, CXR, CSF, throat swab, B/C, U/A

 

If develops hypokalemia (K < 3mmol/l) : 
Think about temporarily suspending the insulin 
Discuss urgently with a critical care specialist,
because a CVC is needed for intravenous administration of potassium solutions above 40 mmol/l 

- Start IV insulin infusion 1-2 hours after intravenous fluid therapy.
- Do not give bolus doses of intravenous insulin.
- Dose 0.05-0.1 U/kg/hr
- Do not give IV sodium bicarbonate to children and young people with DKA.
- Be aware that there is a significant risk of femoral vein thrombosis
  in young and very sick children with DKA who have femoral lines inserted.
 

- Ketosis is resolving and oral fluids are tolerated if Ketone<1.0 mmol/litre
- Start SC insulin at least 30 minutes before stopping IV insulin.

- Cerebral edema : mannitol (20% 0.5-1 g/kg over 10-15 minutes) or
  hypertonic saline (2.7% or 3% 2.5-5 ml/kg over 10-15 minutes)

- Other Complications : 
  Hypoglycemia and Hypokalemia
  Systemic Infections
  Aspiration pneumonia

IV fluid replacement in pediatric DKA.
過快的 IV infusion rate 造成 osmolality 下降
進而發生 Brain edema 
Current recommendation : Slow infusion of isotonic fluids 

NEJM Conclusions : 
Neither the rate of administration nor the sodium chloride content of IV fluids
significantly influenced neurologic outcomes in children with DKA. 

Rehydration for Diabetic Ketoacidosis in Children 2018 NEJM
https://www.facebook.com/TheNewEnglandJournalofMedicine/videos/10155949903668462/