Sugar Is Bad For Kids- Pediatric DKA with Dr. George Willis

The management of diabetic ketoacidosis (DKA) in children is full of difficult questions- how much insulin should I give? Who is at risk for cerebral edema? What treatments, if any, increase the risk for this dreaded complication? Which fluid is ideal? How much of this fluid should I give? We sat down with ED physician and endocrine aficionado Dr. George Willis to answer these questions.

Diabetic ketoacidosis (DKA) is a life-threatening condition usually seen in patients with type I diabetes. DKA is characterized by hyperglycemia, metabolic acidosis, and ketosis. It can present with nausea, vomiting, abdominal pain, tachypnea, polyuria, and altered mental status. [1] Not uncommonly, DKA can be the first presentation of a patient’s diabetes. Treatment includes fluid and electrolyte repletion, correction of the underlying insulin deficiency, and identifying and addressing the precipitating cause (e.g. medication nonadherence, infection). In this episode, Dr. George Willis joins us to delve into the nuances of insulin and fluid management in the pediatric population.

How should we administer insulin to pediatric DKA patients?

• Infusion of insulin without a bolus is preferred.

• Treatment with bolus insulin plus infusion has higher rates of hypoglycemia than infusion alone. Studies have not shown a true correlation or causation between insulin bolus and incidence of cerebral edema.

• Dose infusion at 0.1 units/kg/hr.

• Consider dose of 0.05 units/kg/hr in patients younger than 5 years or in patients with new onset diabetes (as their blood sugar may drop quicker).

• No utility of 0.14 units/kg/hr dosing in pediatric population.

When can we stop worrying about cerebral edema?

• Most cases of cerebral edema occur in patients younger than 15-18 years old.

• There are case reports of young adults (as old as 26 years) who develop cerebral edema. Many of these cases in young adults are in patients with new onset diabetes.

• You can never truly stop worrying about cerebral edema, but be most vigilant in those patients younger than 18 years old and/or in those with new onset diabetes.

We don’t use a bolus of insulin in the pediatric population. . . should we in adults?

• There is no additional benefit to bolus plus infusion versus infusion alone.

• There may actually be a trend towards harm. [2]

• Goyal et al. founnd a trend toward a higher incidence of hypoglycemic and hypokalemic events.[2]

• Keep things simple, just use an infusion at 0.1 units/kg/hr.

How much fluid should we be administering?

• Studies have not demonstrated a difference in development of cerebral edema between different volumes or salinity of fluids. [3-5]

• British Society of Paediatric Endocrinology and Diabetes has new, simple guidelines that help answer this question. [6]

  • For patients in shock, give 20mL/kg bolus over 15 min, reassess and give 10 mL/kg boluses (up to 40mL/kg total)

  • After 40 ml/kg total bolus, consider inotropes to avoid additional fluid.

  • For patients not in shock, give a 10mL/kg bolus over 60 minutes, then reassess.

What type of fluid should we be administering?

• Although studies have not shown a difference in outcomes between balanced solutions (PlasmaLyte or LR) and normal saline in the pediatric population, it is likely good practice to use balanced solutions. It is acceptable to begin resuscitation with normal saline, if that is what is available.

• Hyperchloremic metabolic acidosis may not be as much of an issue in the pediatric population with normal saline, as smaller volumes are generally given.

• If you run into compatibility issues with balanced solutions (eg. antibiotics with plasmalyte), you have a few options;

  • Place a second line

  • Switch to oral medications

  • Administer an alternative medication that is compatible with the IV fluid

In pediatric patients with DKA, administer insulin as an infusion without a bolus. In most patients, the dose is 0.1 units/kg/hr. However, consider dosing at 0.05 units/kg/hr in young patients (<5yo) or new onset diabetics. You can never forget about cerebral edema, but recognize it is usually seen in patients younger than 18 yo, though young adults with new-onset diabetes have been shown to be at risk as well.

Concerning fluid management, give a 20mL/kg bolus to patients with shock, and a 10mL/kg bolus to those not in shock. We recommend using a balanced solution (such as PlasmaLyte or Lacated Ringers), though it is perfectly acceptable to begin resuscitation with normal saline, if that is what is readily available. Know that balanced solutions are not compatible with certain medications, and you may need to be flexible; whether that means placing a second line, administering po meds, or giving an alternative medication that is compatible with your balanced solution.

Check out the Barbara Bush Pediatric DKA IV Fluid Roadmap

 Have a listen to our AWESOME interview with Dr. George Willis here:

Show notes written by Sam Lloyd, Mike Burla, Jeffrey Holmes

Peer Reviewed by Jeffrey A. Holmes, MD

References

[1]  Glaser N. (2020, Aug 13). Diabetic ketoacidosis in children:  Treatment and complications.  UpToDate.  9/3/2020.  [URL]

[2]  Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010;38(4):422-427. [Pubmed]

[3]  Menchine M, Arora S. EMA April 2020, Abstract 7: Intravenous fluid bolus rates and pediatric DKA [Podcast]. EM:RAP. 2020. [URL]

[4]  Pruitt LG, Jones G, Musso M, Volz E, Zitek T. Intravenous fluid bolus rates and pediatric diabetic ketoacidosis resolution. Am J Emerg Med. 2019;37(12):2239-2241. [Pubmed]

[5]  Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378(24):2275-2287. [Pubmed]

[6]  BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. BSPED. 2020. [URL]

Authors: Dr. Jason Hine and Dr. George Willis

Peer Review: Dr. Mike Burla and Dr. Jeff Holmes