Ongoing monitoring for complications

ongoing monitoring for complications

The main dangers once treatment has started are

• cerebral oedema
• look for sign and symptoms suggestive of cerebral oedema
  • headache & slowing of heart rate
  • change in neurological status (restlessness, irritability, increased drowsiness, incontinence)
  • specific neurological signs (eg. cranial nerve palsies)
  • rising BP, decreased O2 saturation
  • abnormal posturing
  • dramatic changes such as convulsions, papilloedema, respiratory arrest are late signs
  • associated with extremely poor prognosis
• if cerebral oedema is suspected inform senior staff immediately and arrange transfer to PICU
  • exclude hypoglycaemia as a possible cause of any behaviour change
  • give hypertonic (2.7%) saline (5mls/kg over 5-10 mins) or Mannitol 0.5 - 1.0 g/kg stat (= 2.5 - 5 ml/kg Mannitol 20% over 20 minutes). This needs to be given as soon as possible if warning signs occur (eg headache or pulse slowing).
  • restrict IV fluids to 1/2 maintenance and replace deficit over 72 rather than 48 hours
  • discuss with PICU consultant. Do not intubate and ventilate until an experienced doctor is available
  • once the child is stable, exclude other diagnoses by CT scan - other intracerebral events may occur (thrombosis, haemorrhage or infarction) and present similarly
  • a repeated dose of Mannitol may be required after 2 hours if no response
  • document all events (with dates and times) very carefully in medical records
• hypoglycaemia &hypokalaemia
• avoid by careful monitoring and adjustment of infusion rates
• consideration should be given to adding more glucose if BG falling quickly even if still above 4 mmol/l (1).

Serum urea and electrolytes should be repeated two hours after starting treatment and thereafter as required; the blood glucose should be measured every two hours. Regular blood gas analysis can give a good indicator of improvement.

Reference:

• (1) British Society of Paediatric Endocrinology and Diabetes (BSPED) 2013. Guidelines for the management of DKA in young people under the age of 18 years