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    CAD Completo 2023

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    SAMUEL MARIN FUQUENE

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    1019728, 1051 Pediatric Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf [NCBI Bookshelf. service ofthe Nationa Library of Medicine, National Institutes of Health ‘StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan- Pediatric Diabetic Ketoacidosis Authors Noha EL-Mohandes!; Garrett Yee”; Beenish S. Bhutta®; Martin R. Huecker* * UHND 2 The Permanente Mecical Group $ Sheikh Zayed Hospital, Lahore 4 University of Louisville Last Update: Ape 9, 2028, Continuing Education Activity Diabetic ketoacidosis (DKA) is a serious complication of relative insulin deficiency affecting primarily type-1 diabetes mellitus (DM). DKA can occur in type-2 DM when insulin levels fall far behind the body's needs. DKA is so named due to high levels of water-soluble ketone bodies (KBs), leading to an acidotic physiologic state. Ketone bodies, while always present in the blood, increase to pathologic levels when the body cannot utilize glucose: low blood glucose levels during fasting, starvation, vigorous exercise, or secondary to a defect in insulin production. This activity reviews the etiology, presentation, evaluation, and management of diabetic ketoacidosis in the pediatric population and examines the role of the interprofessional team in evaluating, diagnosing, and managing the condition, Objectives: + Describe the pathophysiology of pediatric diabetic ketoacidosis. + Review the evaluation of a patient with pediatric diabetic ketoacidosis, including all necessary laboratory tests. + Summarize the management options for diabetic ketoacidosis + Explain modalities to improve care coordination among interprofessional team members to improve outcomes for pediatric patients affected by diabetic ketoacidosis. Access free multiple choice questions on this topic. Introduction Diabetic ketoacidosis (DKA) is a serious complication of relative insulin deficiency affecting primarily type-1 diabetes mellitus (DM). DKA can occur in type-2 DM when insulin levels fall far behind the body's needs. DKA is so named due to high levels of water-soluble ketone bodies (KBs), leading to an acidotic physiologic state.[1][2] According to the International Society for Pediatric and Adolescent Diabetes, DKA is defined by the presence of all of the following in a patient with diabetes: + Hyperglycemia — Blood glucose >200 mg/dL (11 mmol/L) + Metabolic acidosis — Venous pH <7.3 or serum bicarbonate 7.3 or serum bicarbonate >15 mEq/L IV Fluids: Treats dehydration and also hyperglycemia |. Initial IV fluid bolus of 10 mL/kg of normal saline or lactated ringers. 2. Ifthe patient presents with shock, a second 10 mL/kg IV fluid bolus may be given. ‘As mentioned above, hyperglycemia contributes to pseudohyponatremia, Therefore sodium should be continuously monitored, and higher concentrations of sodium should be used in IV fluids if sodium levels do not improve or continue to fall with treatment [36] Potassium replacement should depend on close observation and interpretation of lab values. Ifthe initial potassium level reveals hyperkalemia, potassium replacement should be held until potassium normalizes, urinary voiding is confirmed to be intact, and there is normal renal function, Normal initial potassium in an acidotic patient could indicate severely low total body potassium. Patients with normal or low serum potassium require replacement after ruling out renal dysfunction. DKA patients with hypokalemia should have delayed initial insulin infusion; potassium replacement should precede insulin dosing as above.{27] The serum potassium concentration and electrocardiogram can be used for monitoring as needed. Ketoacidosis is resolved when the anion gap is normal, serum BHB is <10.4 mg/dL, and venous pH is 27.3. It is achieved through decreased hepatic production of ketones, enhanced metabolism by insulin, and increased removal by improved rehydration_(27](37] Lactic acidosis is also corrected with improved rehydration. Bicarbonate therapy is generally avoided in children with DKA except in peri-arrest or cardiac arrest patients, life-threatening hyperkalemia, or severe acidosis (pH <6.9 with symptoms). High-level nursing and frequent clinical assessments are ne hours. ary; biochemical blood markers every two Once acidosis is resolved, the anion gap has closed, and the patient is improving clinically, then diet can be reintroduced, and insulin can be switched to subcutaneous injection. Long-acting/baseline insulin should be administered prior to discontinuation of the infusion. Prevention: Determine the cause of the acute DKA episode and work closely with the child and caregivers on a regime, Differential Diagnosis Gastroenteritis Hyperosmolar hyperglycemic nonketotic syndrome Starvation ketosis Myocardial infarction Pancreatitis Alcoholic ketoacidosis Lactic acidosis Sepsis Toxicologic exposure (ethylene glycol, methanol, paraldehyde, salicylate) hips: nebi nim nin govlbooksiNBK470282/2report=printable m4 1019728, 1051 Pediatric Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf Diabetic medication overdose Uremia Respiratory acidosis Respiratory distress syndrome Prognosis Prognosis improves with advances in medical and intensive care, Mortality rates range from 0. to 0.31% in the United States and other resource-developed countries like Canada and United Kingdom.[38] The majority of deaths result from cerebral injury.[39] Mortality rates or higher and resource-limited settings. Complications ‘The most feared complication of pediatric DKA is cerebral injury/cerebral edema: 1 9, Develops in 0.3%-0.9% of pediatric DKA cases. [38] Mortality ranges from 21-24%[38][40][41][40][38] Risk factors: Severe acidosis, severe dehydration, elevated blood pressure, markedly elevated BUN[39] Etiology: Unclear, however initially thought to be to due rapid LV fluid replacement but this is now controversial as a recent PECARN study in 2018 showed no difference in neurological outcomes.[42] Presents at any time before, during, or after treatment, but typically onset is within 12 hours of treatment [39] Signs/Symptoms: Altered mental status, new headache, recurrent vomiting, urinary incontinence, Cushing Triad (bradycardia, irregular respirations, hypertension) Cerebral Edema may not initially be seen on CT imaging of the brain, therefore may still require starting treatment even if the CT head is normal_[43] Tr 1 ifhig suspicion: 1, Mannitol (0.5-1 g/kg IV over 15 minutes): Osmotic diuretic causing withdrawing water from the brain pareneyma, May give a second dose if there is no initial response. 2. Hypertonic (3%) saline 2.5 mL/kg over 30 minutes Neurosurgical consultation Other Complications include: Cognitive impairment ‘Venous thrombosis[44] Pancreatic enzyme elevations ‘Acute kidney injury[45] Hypokalemia Hypoglycemia Rhabdomyolysis hips: nebi nim nin govlbooksiNBK470282/2report=printable ana 10/928, 1051 Pediat Dabetc Ketoaidsis- SatPearls- NCBI Bookshel + Pulmonary edema + Multiple organ dysfunction syndrome * Cardiac arrhythmias Deterrence and Patient Education Education on the disease process of diabetes, including short and long-term complications, should be given to all patients. Parents and children should be taught how and when to check glucose. They should receive education , and the importance of compliance. about how to use oral hypoglycemic meds and/or insulin, medication, side effec Dietitians, nurses, and multi-disciplinary home health can be essential team members in assisting with this education, Pearls and Other Issues Recurrent DKA is a particular problem in adolescents and may be fatal. Early help is advised as soon as the DKA diagnosis is made. It may be precipitated by 1, Poor compliance or understanding of insulin therapy 2. Infections 3. Alcohol and substance use disorders Psychological stress and lifestyle changes Psychiatric disorders, Enhancing Healthcare Team Outcomes Pediatric diabetic ketoacidosis isa life-threatening disorder best managed by an interprofessional team that includes ‘an emergency department clinician, endocrinologist, pediatrician, intensivist, critical care nursing staff, and pharmacists. These individuals are best managed in the ICU and monitored by nurses. Providers should investigate the cause of DKA while providing initial hydration and correction of acidosis, Primary caregivers, pharmacists, and diabetes educators must work together to ensure that the patient is compliant with insulin therapy and monitoring. Nurses can provide dosing for inpatients and can counsel all patients. Pharmacists will verify dosing and monitor potential drug interactions, providing counsel to patient parents, All interprofessional team members are responsible for documenting their observations, interactions, and interventions and informing other team members regarding the patient management in pediatric diabetic ketoacidosis. [Level 5] Any interprofessional team member who detects a change in status should immediately document their findings in the patient's medical record and notify other team members so corrective action can be taken to ensure optimal outcomes in this potentially very ill patient population [46][28][47] Review Questions + Access free multiple choice questions on this topic. + Comment on this article. References hips: nebi nim nin govlbooksiNBK470282/2report=printable ona 1019728, 1051 Pediatric Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf 1 1. 12, 14, Abulebda K, Whitfill 7, Montgomery FE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program. Pediatr Emerg Care. 2021 Nov 01;37(11):543- 549, [PubMed: 30870337] Agarwal HS. Subclinical cerebral edema in diabetic ketoacidosis in children, Clin Case Rep. 2019 Feb;7(2):264- 267. [PMC free article: PMC6389473] [PubMed: 30847186] Mayer-Davis EJ, Kahkoska AR, Jefferies C, Dabelea D, Balde N, Gong CX, Aschner P, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes. 2018 Oct;19 Suppl 27(Suppl 27):7-19. [PMC free article: PMC7521365] (PubMed: 30226024] Flood K, Nour M, Holt T, Cattell V, Krochak C, Inman M. Implementation and Evaluation of a Diabetic Ketoacidosis Order Set in Pediatric Type I Diabetes at a Tertiary Care Hospital: A Quality-Improvement Initiative. Can J Diabetes. 2019 Jul;43(5):297-308. 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Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-I DM in young children and adolescents living in a developing country - an experience from a pediatric emergency department. J Pediatr Endocrinol Metab. 2019 Feb 25;32(2):115-119. [PubMed: 30699071] Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child, 2001 Jul;85(1):16-22. [PMC free article: PMC1718828} [PubMed: 11420189} Sapru A, Gitelman SE, Bhatia S, Dubin RF, Newman TB, Flori H, Prevalence and characteristics of type 2 diabetes mellitus in 9-18 year-old children with diabetic ketoacidosis. J Pediatr Endocrinol Metab. 2005 Sep;18(9):865-72. [PubMed: 16279364] Wolfsdorf J, Glaser N, Sperling MA., American Diabetes Association, Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. 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[PMC free article: PMC370361) (PubMed: 6134753] Edgerton DS, Ramnanan CJ, Grueter CA, Johnson KM, Lautz M, Neal DW, Williams PE, Cherrington AD. Effects of insulin on the metabolic control of hepatic gluconeogenesis in vivo. Diabetes. 2009 Dee;58(12):2766- 75. [PMC free article: PMC2780867] [PubMed: 19755527] Owen OE, Trapp VE, Skutches CL, Mozzoli MA, Hoeldtke RD, Boden G, Reichard GA. Acetone metabolism during diabetic ketoacidosis. Diabetes. 1982 Mar;31(3):242-8, [PubMed: 6818074] Kangin M, Talay MN, Tanriverdi Yilmaz $, Unal E, Demiral M, Asena M, Ozbek MN. A Retrospective Analysis of Children and Adolescents With Diabetic Ketoacidosis in the Intensive Care Unit: Is Tt Significant that the Blood Ketone Level Becomes Negative in Diabetic Ketoacidosis? Cureus. 2020 Oct 08;12(10):e10844, [PMC free article: PMC7651777] [PubMed: 33178500] Tantiwong P, Puavilai G, Ongphiphadhanakul B, Bunnag P, Ngarmukos C. 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[PubMed: 30417497] Abbas Q, Arbab S, Haque AU, Humayun KN, Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit. Pak J Med Sci. 2018 Jan-Feb;34(1):106-109. [PMC free article: PMC5856992] [PubMed 29643888] Baalaaji M, Jayashree M, Nallasamy K, Singhi S, Bansal A. Predictors and Outcome of Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian Pediatr. 2018 Apr 15;55(4):311-314. [PubMed: 29428918] Wolfsdorf JL. The Intemational Society of Pediatric and Adolescent Diabetes guidelines for management of diabetic ketoacidosis: Do the guidelines need to be modified? Pediatr Diabetes. 2014 Jun;15(4):277-86. (PubMed: 2486064] Dabelea D, Pihoker C, Talton JW, D'Agostino RB, Fujimoto W, Klingensmith GJ, Lawrence JM, Linder B, Marcovina SM, Mayer-Davis EJ, Imperatore G, Dolan LM., SEARCH for Diabetes in Youth Study. Etiological tps: nebi nim nin govlbooksiNBK470282/2report=printable sina 10/928, 1051 Pediat Dabetc Ketoaidsis- SatPearls- NCBI Bookshel approach to characterization of diabetes type: the SEARCH for Diabetes in Youth Study. Diabetes Care, 2011 Jul;34(7):1628-33. [PMC free article: PMC3120176] [PubMed: 21636800] 33. Weinberger K, Seick Barbarini D, Simma B. Adherence to Guidelines in the Treatment of Diabetic Ketoacidosis in Children: An Austrian Survey. Pediatr Emerg Care, 2021 May 01;37(5):245-249, [PubMed: 30045350] 34. Gunn ER, Albert BB, Hofman PL, Cutfield WS, Gunn AJ, Jefferies CA., Starbase Diabetes Working Group, Paediatric Diabetes Service, Starship Children’s Hospital, Auckland, New Zealand, Pathways to reduce diabetic ketoacidosis with new onset type I diabetes: Evidence from a regional pediatric diabetes center: Auckland, New Zealand, 2010 to 2014. Pediatr Diabetes. 2017 Novs18(7):553-558. [PubMed: 27726271] 35, Abulebda K, Abu-Sultaneh S, White EE, Kirby ML, Phillips BC, Frye CT, Murphy LD, Lutfi R. Disparities in Adherence to Pediatric Diabetic Ketoacidosis Management Guidelines Across a Spectrum of Emergency Departments in the State of Indiana: An Observational In Situ Simulation-Based Study. Pediatr Emerg Care. 2018 Apr 24; [PubMed: 29698339] 36, Glaser NS, Stoner MJ, Garro A, Baird S, Myers SR, Rewers A, Brown KM, Trainor JL, Quayle KS, MeManemy JK, DePiero AD, Nigtovie LE, Tzimenatos L, Schunk JE, Olsen CS, Casper TC, Ghetti S, Kuppermann N., Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group. Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics. 2021 Sep;148(3) [PubMed: 34373322] 37. Noyes KJ, Crofton P, Bath LE, Holmes A, Stark L, Oxley CD, Kelnar CJ. Hydroxybutyrate near patient testing (o evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children Pediatr Diabetes. 2007 Jun;8(3):150-6. [PubMed: 17550425] 38. Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr. 2005 May;146(5):688-92, (PubMed: 15870676] 39. Glaser N, Bamett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N., Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk factors for cerebral edema in children with diabetic ketoacidosis, The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25;344(4):264-9. [PubMed: 11172153] 40. Marcin JP, Glaser N, Bamett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N., American Academy of Pediatrics. The Pediatric Emergency Medicine Collaborative Research Commitee, Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema, J Pediatr. 2002 Dec;141(6):793-7. [PubMed: 12461495] 41. Scibilia J, Finegold D, Dorman J, Becker D, Drash A. Why do children with diabetes die? Acta Endocrinol Suppl (Copenh). 1986;279:326-33. [PubMed: 3096039] 42, Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, Myers SR, Nigrovie LE, Gatto A, Brown KM, Quayle KS, Trainor JL, Tzimenatos L, Bennett JE, DePiero AD, Kwok MY, Perry CS, Olsen CS, Casper TC, Dean JM, Glaser NS., PECARN DKA FLUID Study Group. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018 Jun 14:378(24):2275-2287. [PMC fiee article PMC6051773] (PubMed: 29897851] 43, Krane EJ, Rockoff MA, Wallman JK, Wolfsdorf JI. Subclinical brain swelling in children during treatment of diabetic ketoacidosis. N Engl J Med. 1985 May 02;312(18):1147-51, [PubMed: 3920521] 44, Worly IM, Fortenberry JD, Hansen I, Chambliss CR, Stockwell J. Deep venous thrombosis in children with diabetic ketoacidosis and femoral central venous catheters, Pediatrics. 2004 Jan;113(1 Pt 1):e57-60. [PubMed: 14702496] 45, Hursh BE, Ronsley R, Islam N, Mammen C, Panagiotopoulos C. Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis. JAMA Pediatr. 2017 May 01;171(5):e170020. [PubMed: 28288246] 46. Foster NC, Beck RW, Miller KM, Clements MA, Rickels MR, DiMeglio LA, Maahs DM, Tamborlane WV, Bergenstal R, Smith E, Olson BA, Garg SK. State of Type 1 Diabetes Management and Outcomes from the TID hips: nebi nim nin govlbooksiNBK470282/2report=printable vane 1019728, 1051 Pediatric Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf Exchange in 2016-2018. Diabetes Technol Ther, 2019 Feb;21(2):66-72. [PMC free article: PMC7061293] [PubMed: 30657336] 47, Sildorf SM, Breinegaard N, Lindkvist EB, Tolstrup JS, Boisen KA, Teilmann GK, Skovgaard AM, Svensson J. Poor Metabolic Control in Children and Adolescents With Type 1 Diabetes and Psychiatric Comorbidity. Diabetes Cate, 2018 Novs4l(11):2289-2296. [PubMed: 30270201] Disclosure: Noha EL-Mohandes declares no relevant financial relationships with ineligible companies. Disclosure: Garrett Yee declares no relevant financial relationships with ineligible companies. Disclosure: Becnish Bhutta declares no relevant financial rlationships with incligible companies. Disclosure: Martin Huecker declares no relevant financial relationships with ineligible companies, htps:www neti nim nin govlbooksiNBK470282/2report=printable ran Podiatric Diabetic Ketoacdosis- StatPearls - NCBI Bookshelf 10/9723, 1051 Tables Features Mild DKA. ModerateDKA Severe DKA Venous pH 7210<73 TA t0<7.2 <1 10 to <15* 5109

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