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/
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