Pediatric emergency medicine trisk 1869 1869
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ventilation may also be considered in order to support the patient’s efforts to achieve a
respiratory alkalosis. If intubated, the patient should be initially hyperventilated to the PCO 2
they were maintaining prior to the neurologic decompensation (generally 10 to 20 mm Hg in
the presence of severe ketoacidosis); this can be gradually reduced over several hours as the
acidosis resolves and the cerebral edema is treated.
Only after the patient is fully stabilized should a confirmatory computed tomography of the
head be considered, unless a diagnosis of intracerebral hemorrhage or thrombosis is strongly
suspected.
Clinical Indications for Discharge or Admission
Close monitoring is mandatory, and a well-organized flowsheet ensures all parameters are
being observed. Admission to an intensive care unit or specialized intermediate care unit
should be considered for DKA management. The patient should be maintained on continuous
cardiorespiratory monitoring with hourly assessments of blood pressure and level of
consciousness until the patient’s trajectory of illness has been clearly established. Careful
neurologic examination, with particular attention to level of cognition and pupillary reactivity,
should be performed frequently. The fluid input and output must be reviewed hourly to ensure
appropriate rehydration is occurring. The IV fluids should be checked frequently so that pump
failure or fluid leakage into the subcutaneous tissues can be corrected quickly. In the severely
ill child, an ECG should be performed in the setting of hyperkalemia or hypokalemia. The
plasma glucose should be measured hourly until the blood glucose is stable and less than 300
mg/dL, and as long as the child is on an insulin infusion. Glucose measurement may be less
frequent once the patient has been changed to subcutaneous insulin. Serum [K+ ] needs to be
measured every 2 to 4 hours until the acidosis and hyperglycemia are normalized, or more
frequently if hypokalemia is encountered or bicarbonate therapy is used. Calcium, phosphate,
and magnesium should be assessed initially and followed every 2 to 4 hours, more frequently
if any are being actively replaced. With the advent of point-of-care ketone measurements, it
may be advisable to follow serum ketone concentration every 2 to 4 hours, although
continuous noninvasive capnography with nasal cannula end-tidal CO2 (ETCO2 ) or
transcutaneous CO2 monitoring is also useful in tracking the degree of acidosis over time.
Venous pH may be obtained to follow resolution of the acidosis if the above monitoring
options are not available. Arterial sampling is not necessary for metabolic monitoring, and
central venous access is rarely necessary.
When the child is better hydrated and the acidosis resolves, mental alertness will improve
and symptoms of nausea, vomiting, and abdominal pain should remit. If they do not resolve,
an abdominal disorder should be considered. Some patients complain of blurred vision, which
is caused by lens distortion resulting from fluid shifts of rehydration and correction of
hyperglycemia—this should resolve within 24 hours of conclusion of therapy. When the anion
gap has closed, most patients are able to tolerate oral fluids, at which point rehydration can be
continued orally ad libitum.
MILD KETOACIDOSIS/HYPERGLYCEMIA
Goals of Treatment
