A 10 year old girl presents with likely DKA (her ketones were in fact 7).HAGMA with partial compensation (expected CO2 is 23)

Pseudohyponatraemia

Moderate hypokalaemia (ie. total body K depletion, even with normal serum K)

Dehydration – elevated Creatinine (for a child), high Hb, high WCC (concentration effect)

Principles of Management:

1. Resuscitation

2. Correct ketoacidosis, electrolytes, fluid deficit

3. Treat underlying cause

4. Prevent complications

5. Refer to Endocrine/ ICU for ongoing management

Specific treatment:

1. Resuscitation – attention to ABC, Fluid bolus 10ml/kg of 0.9% Saline, repeat if required, catheter

2. Replace K – If K < 5 add 20 mmol to each 500 ml 0.9% saline (check patient is still passing urine first)

3. Fluid replacement – deficit and maintenance is weight based

deficit =  weight X 10 X %dehydration (max 5%) – fluid bolus over 48 hours

maintenance = 4:2:1 rule over 24 hours

Use 0.9% Saline only (with added K)

Change fluid to 0.9% Saline and 5% Dextrose when Glucose < 15

1. Insulin Therapy

0.1 U/kg (subcutaneous bolus if pH > 7.2, infusion if pH<7.2)

then 0.1U/kg every 2 hours if subcut or 0.1U/kg/hr as infusion (50U actrapid in 50 mls 0.9% Saline)

1. Treat underlying cause

2. Prevent/ Monitor/Treat complications

signs of raised intracranial pressure (headache, altered GCS, bradycardia, hypertension) – if present, urgently contact PICU

• Treat with 20% mannitol IV 0.5-1g/kg (2.5-5mls/kg) over 20 mins  or 3% hypertonic saline (3ml/kg) slow push and reduce fluid rate by one third

hypoglycaemia

• Monitor blood glucose and ketones hourly while on insulin infusion

hyponatraemia, hypokalaemia, hyperchloraemic acidosis

• Check electrolytes 2-4 hourly as clinically indicated

Other

• arrhythmias
• venous thrombosis
• infection