A 7-year-old boy is brought to the emergency department with nausea, vomiting, and abdominal pain. He has been increasingly tired for the past month and has experienced abdominal pain and nausea for the past 2 days. His temperature is 36.7 C (98 F), blood pressure is 92/56 mm Hg, pulse is 134/min, and respirations are 24/min. Physical examination shows a tired but cooperative patient with dry mucous membranes. His lungs are clear to auscultation. The abdomen is soft, nondistended, and mildly tender in all quadrants. Bowel sounds are normal. There is no rebound or guarding. Laboratory results are as follows: Urinalysis shows a specific gravity of 1.030, ketonuria, and glucosuria. A 10-mL/kg bolus of normal saline is administered intravenously over an hour. An insulin drip is then started. Which of the following is the most appropriate next step in management of this patient?

Question

A 7-year-old boy is brought to the emergency department with nausea, vomiting, and abdominal pain.  He has been increasingly tired for the past month and has experienced abdominal pain and nausea for the past 2 days.  His temperature is 36.7 C (98 F), blood pressure is 92/56 mm Hg, pulse is 134/min, and respirations are 24/min.  Physical examination shows a tired but cooperative patient with dry mucous membranes.  His lungs are clear to auscultation.  The abdomen is soft, nondistended, and mildly tender in all quadrants.  Bowel sounds are normal.  There is no rebound or guarding.  Laboratory results are as follows:  Urinalysis shows a specific gravity of 1.030, ketonuria, and glucosuria.  A 10-mL/kg bolus of normal saline is administered intravenously over an hour.  An insulin drip is then started.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beb6_e3f7_8f63_1525fdd1950e_MD0005_00 This patient's clinical presentation is consistent with diabetic ketoacidosis (DKA). Mild cases of DKA with no vomiting can be managed by an experienced outpatient team or on a general inpatient ward. However, patients with severe DKA (eg, pH <7.1, bicarbonate <5 mEq/L, altered mental status) should be admitted to an intensive care unit for close monitoring as they are at greatest risk for complications (eg, cerebral edema). Treatment of severe DKA begins with volume repletion with isotonic fluids (eg, normal saline, Ringer's lactate) given over an hour followed by initiation of an insulin drip. A small bolus given over an hour prior to initiating insulin therapy has been shown to minimize the risk of cerebral edema compared to starting an insulin drip immediately. Potassium-containing intravenous (IV) fluids should be administered simultaneously with the insulin drip for patients with normal or low potassium levels as insulin moves potassium intracellularly and causes hypokalemia. Ongoing management consists of blood work every 1-2 hours and close titration of IV fluids to correct electrolyte derangements and acidosis. During this period, patients should be closely monitored for signs of cerebral edema such as altered mental status, lethargy, headache, and vomiting. A head CT should be ordered for patients in whom cerebral edema is suspected. Once the metabolic acidosis has resolved and the anion gap has closed, the patient can be transitioned to a subcutaneous insulin regimen. cerebral edema (Choice A) Bicarbonate should not be added to the IV fluids as it has not been shown to be beneficial. In addition, bicarbonate administration can cause hypokalemia, cerebral edema, and metabolic alkalosis. (Choices C and D) Although an infection can sometimes precipitate DKA, a bacterial infection is unlikely in the absence of fever, leukocytosis, pyuria, or bacteriuria. This patient has a normal temperature, normal white blood cell count, and a non-infectious urinalysis. Blood culture, urine culture, and antibiotics are therefore unnecessary. (Choice E) Serum lipase is used to diagnose pancreatitis, and abdominal CT is used to diagnose appendicitis and other causes of an acute abdomen. Although the clinical presentation of DKA can mimic that of acute gastroenteritis or other gastrointestinal pathology, these conditions do not present with hyperglycemia and metabolic acidosis. Educational objective: Diabetic ketoacidosis is defined as metabolic acidosis (pH <7.3 or serum bicarbonate <15 mEq/L) in the setting of hyperglycemia (serum glucose >200 mg/dL). Treatment consists of volume repletion with a normal saline bolus given over an hour followed by initiation of an insulin drip and potassium-containing intravenous fluids for patients with low to normal potassium levels. These patients require hospitalization in an intensive care unit. References: Management of diabetic ketoacidosis in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/18590342) Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. (http://www.ncbi.nlm.nih.gov/pubmed/24685959) ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents (http://www.ncbi.nlm.nih.gov/pubmed/14736641)

A 7-Year-Old Boy Is Brought to the Emergency Department with Nausea