Rattibha

Shane Fitzgerald

15 Tweets 21 reads Mar 19, 2022

🏨A Case from our Paeds Emergency Simulation Day🚨
3 yr old BIBA, parents concerned about his fast breathing..
Unwell for a few days, low grade fever.
SpO2 100%, HR 140, RR 50, BP 80/50mmHg, Temp 37.4 °C
His chest is clear on auscultation, no wheeze or creps, CRT 3sec..

2/ What is the first test/intervention you would perform?

3/ A helpful nurse performs a bedside glucose check:
BM 18 & Ketones 3.1mmol/L
What next test will be the most helpful?

4/ Well done! You perform a blood gas:
pH 7.21, CO2 4, HCO3 11, BE -6
What is his diagnosis?

5/ Correct answer: Mild DKA
Mild DKA: pH 7.2-7.29 &/or HCO3 <15
Moderate DKA: pH 7.1-7.19, HCO3 <10
Severe DKA: pH <7.1, HCO3 <5

6/ Fluid Requirements
He is started on a fluid bolus of 0.9% NaCl 10ml/kg. What maintenance fluids does he require?

7/ Correct answer is B.
Calculate the fluid deficit based on whether child has mild/mod/severe DKA (see initial blood gas).
Deficit = % dehydration x Body Wt (Kg) x 10
Deficit = 5% x 14kg x 10 = 700ml

8/ Fluid Requirments:
Deficit - bolus = 700ml - 140ml = 560ml to be replaced over 48hrs
= 11.6ml/hr
Maintenance = 1400ml/24hr = 58.3ml/hr
Total fluids = 11.6 + 58.3 = 70ml/hr

9/ Potassium
Our patients U&E comes back: Na 128, K 5.5, he has had 1x wet nappy this morning.
What type of fluids will you commence?

10/ Total body Potassium (K) is almost always depleted in DKA, regardless of the serum level.
Where K is at the upper limit of normal range (<5.5mmol) at presentation with a recent history of passing urine (confirm they are not anuric), NICE recommends adding K to fluids

11/ Insulin
When will you commence Insulin as an infusion?

12/ Insulin
Correct answer is B.
There is some evidence cerebral oedema is more likely if insulin is started early.
Once rehydration fluids & K are running, serum Glu will start to fall.

13/ Learning points:
Don’t forget to check a BM in children with tachypnoea, especially if the picture doesn’t fit with all the other wheezers you’ve seen on your shift!
Take your time with fluid calculations and always get someone to check with you.