ENDOCRINE

ResponseBSL>11 (Or known to have DM)
Venous pH <7.3 OR Bicarb <15
Ketonaemia/ketonuria
RCH Jul ‘24

ResponseInadequate insulin
First presentation of illness

ResponseDon’t expect to be given ketones.
HAGMA (AG + Delta ratio) - the gap comes from ketones

• May be concurrent met alk due to vomiting
• ?respiratory compensation

Sodium: reads as low due to dilution from hypoglycaemia. Often corrects to high as dehydrated:

• Corrected sodium = Sodium + (Glucose-5)/3

Potasium high - due to acidosis

• Corrected potassium ~ increases 0.5 for every 0.1 drop in pH below 7.4
  Eg: pH 7.2, K+ 4.0, drop is 0.2 so K+ drops 0.5x2, so corrected K is 3.0

Chloride often low - maintains electrical neutrality - loss from kidneys in face of other anions (Ketones)

ResponseSerum Ketones (Finger prick) - Monitor response to treatment with serial monitoring
EUC - ?pre-renal renal failure with DKA
Urine - ? UTI, surrogate for serum ketones
CXR ? pneumonia
CTB - ? cerebral oedema if altered LOC
Serum antibotides - first presentation of DKA

ResponseMove to resus, IVC +/- Central access for K+ replacement
IV fluids - 1L N/S stat, then replace losses + give maintenance
Insulin infusion: Actrapid 0.1U/kg/hr (~5U/hr). BSL should drop 2-4 per hour. End point is resolution of ketosis
Potassium replacement - add 40 mmol/L to fluids when K <5 (only if passing urine) - Other option is minibags
Glucose - Swap IV fluids to 5% dextrose when BSL <15
Maintain SBP >100
Monitor K+, Na (large drops = seizure), BSL and Ketones
Seek and treat cause
HDU admission

ResponseFluids:

• Fluid Bolus: N/S 10 mL/kg bolus (repeat x 2) - aim for improved perfusion (Cap refil <3s, improved GCS, HR, BP)
• Rehydration fluids: N/S until BGL <15, then swap to 5% dextrose + 0.9% N/S Replace deficit over 24-48 hours
• Rate = full maintenance + deficit over 24-48 hours. expect 5-7% dehydration if passing urine

Potassium: Add 40 mmol KCL to each bag once K <5.5 and not anuric
Insulin: Actrapid - 0.1U/kg/hr infusion to commence after 1 hour
VBG’s - Q30 min check electrolytes + Glucose

• If glucose dropping >5/hr change to 10% dextrose

Cardiac monitoring, nurse head up, O2, IDC
Seek and treat precipitant (Probably give IVABx is toxic child)
Disposition: Paediatric HDU vs Retrieval to paeds hospital

ResponseBicarbonate is not given in HSS or DKA unless severe acidosis or toxic ingestion (?may be given if profound hyperkalaemia)

ResponseLess dramatic, higher mortality (10%)than DKA (1-4%)! Issue is primarily dehydration (so rehydration is primary treatment)
Bicarb normal, no ketosis. Stem = Old, sick patient with T2DM

ResponseHAGMA - renal failure, lactate (+?ketosis)
Glucose high as part of HHS
Sodium - corrected is high - Dehydration (corrected sodium = measured sodium + (Glucose -5)/3)
Potassium elevated - decreased renal excretion in AKI + Acidosis
Urea + creatinine high = renal failure.

ResponseInfection/sepsis
Inadequate treatment of diabetes (insulin/oral hypoglycaemics)
others

ResponseHyperkalaemia treatment

• Calcium gluconate 30 mmol
• Sodium bicarbonate 50 mmol - to treat hyperkalaemia not HSS treatment
• Salbutamol, resonium - probably not insulin/dex!

Fluids:

• 500-1000 mL N/S Bolus - aim SBP >100, Cap refil <2s

Insulin:

• Actrapid 0.05 U/kg/hr (3mL/hr) (answers vary - 3 u/hr seems safe)

Seek and treat precipitant - ?IVABx if septic