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Snap Shot
  •  A 12 year old boy, previously healthy, is admitted to the hospiral after 2 days of polyuria, polyphagia, nausea, vomting and abdominal pain. Temp is 37, BP 103/63, HR 112, RR 30. Physical exam shows a lethargic boy.  Glucose is 534, Potasium is 5.9; WBC 16,000, pH is 7.13, PCO2 is 20 mmHg, PO2 is 90 mmHg.
Introduction
  • Results from
    • absolute deficiency in insulin
    • surge in counterregulatory homones (glucagon, growth hormone, catecholamine)
    • results in hyperglycemia and ketonemia
  • Most common in type I diabetes
  • Precipitated by
    • infections
    • MI
    • drugs (steroids, thiazide diuretics)
    • noncompliance
    • pancreatitis
Presentation
  • Symptoms 
    • vomiting
    • abdominal pain
    • Kussmaul Respiration (increased tidal volume)  
    • fruity, acetone odor
    • severely dehydrated
    • cerebral edema
      • associated with high mortality in pediatric patients
Evaluation
  • Diagnostic criteria
    • blood glucose levels > 250 mg/dL
    • Arterial pH < 7.3
      • expect to see an increase in free calcium since the excess hydrogen displaces calcium from albumin 
    • Serum bicarbonate < 15mEq/L
    • Moderate ketonuria and ketonemia
  • Labs show:
    • increased anion gap metabolic acidosis
Treatment
  • Fluids
  • Insulin with glucose 
    • give insulin until ketones are gone, even after glucose normalizes or is below normal
  • Replace potasium for hypokalemia 
    • caused by too much potassium being secreted in the urine as a result of the glucosuria
    • labs may show pseudo-hyperkalemia  
      • due to transcellular shift of potassium out of the cells to balance the H being transfered into the cells 
    • give in the form of potassium phosphate rather than potasium chloride
  • Aggresive electrolyte replacement
    • give phosphate supplementation to prevent respiratory paralysis
  • If mental status changes (headache, obtundation, coma) occur during treatment
    • likely due to cerebral edema
    • give mannitol
  • Follow anion gap to monitor improvement
 

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