ER nurse wanting some info on pediatric hyperglycemia

Pediatric Critical Care Columnist · Feb 11, 2016

One of the most important things to remember about hyperglycemic kids is that bringing their sugar down too quickly can tip them into severe cerebral edema. That can lead to coma and death. I've seen it once, and won't ever forget it. Correcting their acidosis too quickly is also a bad idea. A fluid bolus isn't wrong, because by the time their sugar gets that high, they're significantly dehydrated. Treating a child with DKA is very challenging and there are myriad changes to both their metabolic status and the plan over the course of stabilizing them. Intensive monitoring is vital.

Steps: 1) STAT labs: ABG, blood culture, serum electrolytes, urinalysis, betahydroxybutyrate

2) Fluid resuscitation (20 mL/kg saline), supplemental oxygen, +/- advanced airway management; frequent neurovitals

3) empiric antibiotics if bacterial infection is suspected

4) gradual (

5) gradual correction of acidosis and treatment of hypokalemia; maintenance is twice the usual volume by weight

You'll be changing the composition of your IV fluids frequently based on your ongoing monitoring. Potassium and phosphate are essential - serum K+ must be normal before starting insulin. By the time you get to the point of adding dextrose the child will likely be in PICU, but in case, it's good to know. I've heard newish PICU nurses refer to "just DKA" as if it's a minor thing, but it scares the dickens out of me. I've had patients in DKA who took more than 48 hours to safely bring them into the almost-normal range. It's a busy assignment and not one to be taken lightly.

Thank you for seeking to expand your knowledge of pediatric emergency care.

**NickiLaughs, ADN, BSN, RN** · Feb 12, 2016

Thank you for the info. I was thinking the bolus wasn't a bad call but my ER workers seemed to think it was.

Yes I'm aware of dropping sugars quickly causing severe cerebral edema. I did adult critical care for three years, I just wish I had more peds knowledge because they're so different.

I just was concerned because my coworkers made a big deal about this pedi getting a 20ml per kg bolus over an hour, which appeared to be a prudent order to me and I wouldn't have questioned it had he been my patient. Just the bolus apparently dropped his sugar from 900s to 500s and shortly after he became altered. He was never given insulin. I'm wondering why the appropriate bolus would have raised a red flag. I'm wondering if the nurse gave more fluids than ordered and took much longer to recheck his sugar. I just worry when two coworkers day "oh that was a bad order" when to me it makes sense.

Im with you on DKAs, they make me nervous because of how many different ways the disease process can make things go bad.

Pediatric Critical Care Columnist · Feb 12, 2016

Fluid boluses in peds are usually 20 mL/kg to start - 10 mL/kg if they have a known cardiac history. When you're getting into the 80 mL/kg range it's time to start pressors. They need a full tank. Kids' cardiac output is rate-mediated; they'll increase their heart rate to compensate for falling BP until their rate won't allow enough filling to maintain output. That's why hypotension is such a late, ominous sign. Urine output is much more of an indicator for kids than it is in adults too. We'd be looking for 2 mL/kg/hr in an adequately perfused patient.

LadyFree28, BSN, LPN, RN · Feb 12, 2016

Working in a PediER, usually when we get DKAs, we give a 20mL/kg bolus, re check sugar, a blood gases; then maintenance with insulin therapy, via an insulin drip.

We place an IV for dedicated blood draws and have the insulin drip run piggy back with the maintenance; the insulin is calculated based on the blood sugar; once glucose is 250, my ER uses some form of dextrose; if Potassium is low, then fluids will involve dextrose and Potassium.

I have a pt altered after insulin therapy initiated and drastic changes to their blood gases where they have became acidotic; needing additional correction to their acidotic state-that was stressful enough; then another DKA hours later that was much better, but it was very harrowing to deal with the first one!

**NickiLaughs, ADN, BSN, RN** · Feb 12, 2016

Thanks for that info. So everyone being upset about a 20ml/kg bolus is unfounded. Chances are other factors were involved resulting in his rapid blood sugar drop as opposed to the bolus. Thanks so much for the info everyone. I'm sure I'll be back with more questions and Amazon should be delivering my peds critical care resource book tomorrow. :)

sugarmagnolia3 · Feb 15, 2016

We don't like to drop them more than 100g/dL per hour. We treat DKA with insulin infusion 0.1 units/kg/hr. NO RATE CHANGE IN INSULIN, while titrating a 2 bag system of IVF with a minimum of hourly accuchecks. 1 bag has D10 with electrolyte additives and 1 bag has NS with additives. If the sugar is going down at less than 100 g/hr you run each fluid half and half, and if the sugar drops too much you run just the D10. Not going down enough, just the NS. Do at least hourly neuro assessments looking for any changes in level of conciousness. Have 3% NS and or mannitol on hand just in case. Have never had to give mannitol, but have run 3% NS for a brief period. DKA in adults is kinda like, no big deal (ok it is, but it isn't, and it's usually HHNK, not DKA). With kiddos, it's very scary because they are so prone to developing cerebral edema.

Julius Seizure · Feb 18, 2016

We don't like to drop them more than 100g/dL per hour. We treat DKA with insulin infusion 0.1 units/kg/hr. NO RATE CHANGE IN INSULIN, while titrating a 2 bag system of IVF with a minimum of hourly accuchecks. 1 bag has D10 with electrolyte additives and 1 bag has NS with additives. If the sugar is going down at less than 100 g/hr you run each fluid half and half, and if the sugar drops too much you run just the D10. Not going down enough, just the NS. Do at least hourly neuro assessments looking for any changes in level of conciousness. Have 3% NS and or mannitol on hand just in case. Have never had to give mannitol, but have run 3% NS for a brief period. DKA in adults is kinda like, no big deal (ok it is, but it isn't, and it's usually HHNK, not DKA). With kiddos, it's very scary because they are so prone to developing cerebral edema.

Same here. Insulin gtt does not change rate. We hang it Y'd in with two maintenance fluids - NS+KCL+KPhos, and D5NS+KCL+Kphos. Start with only the NS fluid running, and as the BS decreases, we switch to 1/2 and 1/2 of each fluid, then entirely to the D5NS fluids. (Assuming we see appropriate response with the glucose checks hourly, of course.) Our protocol is that we never go backward....i.e. once the NS is changed to D5NS we never change back unless the doctor specifically orders that. BMP checked every 4-6 hours, and once the CO2 on the BMP is less then 15, we allow them to have clears. Not my fav patient assignment.

sugarmagnolia3 · Feb 18, 2016

Discussed this post with my peds intensivist. He said 20ml/kg bolus is protocol and an expected order. Did you start insulin in conjunction with the NS? Insulin shouldn't be started until after the bolus is complete and the sugar is re-checked. We run into issues in the PICU when the ED boluses + starts the gtt with no sugar simultaneously running, and by the time they get up to PICU, and get their sugar rechecked, sometimes they are lower than we would like to see them...From our standpoint, we'd like to see the ED either 1) bolus only and let us start the insulin or 2) start the gtt with fluids that contain dextrose.

sugarmagnolia3 · Feb 18, 2016

Great topic btw, and good for you for ordering the book! Let us know if you like your book. I have one that I'm not crazy about. I worked in adult ICU before switching to PICU a year and-a-half ago. Lots of similarities, but lots of BIG difference too! They are not just "little adults"