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Archive for October, 2011

MSH Peds DKA Guideline

GUIDELINES FOR PEDIATRIC MANAGEMENT OF DIABETIC KETOACIDOSIS

This is not intended as a rigid protocol, but is offered as a guideline. Discuss each case promptly with the Pediatric Endocrine Fellow or Attending on call. Each case needs individual assessment and frequent reassessment with the diabetes team during the course of treatment.

*** 24-hour Pediatric Endocrine/Diabetes Contact via 212-241-6936. ***

EMERGENCY ASSESSMENT
First confirm the diagnosis of DKA (exclude other conditions i.e. ASA overdose). Then assess the severity of metabolic abnormality and plan gradual correction of dehydration, acidosis, hyperglycemia and hyperosmolality.

History: Duration of illness, symptoms (polydipsia, polyphagia), assessment of fluid loss (polyuria, nocturia, vomiting), weight loss (previous known weight), abdominal pain, nausea and fatigue. Medications (i.e. steroids). If established diabetes – Usual diabetes management: insulin regimen and time of last insulin injection/omission.

Physical Examination: Weight (kg); Vital signs (BP, HR, RR, T); Dehydration (dry mucous membranes, skin turgor, capillary perfusion, peripheral pulses); Level of consciousness; Fundoscopic exam; Fruity odor breath; Kussmaul respirations; Focus of infection. (NB: signs of shock include ¯ BP, ­ pulse, cap. refill >3 sec, skin – cool, pale).

INITIAL ASSESSMENT and MONITORING
Do – Fingerstick glucose and urine dipstick. Start 2 large bore IV lines. Send – VBG (STAT), SMA-10, amylase, preserved glucose, serum osmolality, CBC with differential, HbA1C and urine analysis. Calculate serum osmolality: (Na + K mEq/L) x 2 + glucose mg/dl
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If newly diagnosed diabetes obtain before starting insulin treatment: Total insulin, C-peptide, DM related autoantibodies (anti Insulin Ab, anti GAD Ab, anti Islet cell Ab) and send to lab. Save 5 –10 cc in speckled top tube to give to Endocrine fellow.
ECG to check T-waves. If clinically indicated – Urine pregnancy, Urine toxicology screen, Cultures, CXR.
Establish Severity of Ketoacidosis:
Mild Venous pH < 7.3 and/or serum bicarbonate <15 mmol/L Moderate Venous pH < 7.2 and/or serum bicarbonate <10 mmol/L Severe Venous pH < 7.1 and/or serum bicarbonate < 5 mmol/L E. Monitoring: Q 1 hr – VBG, Fingerstick glucose and vital signs; Q 2 hr – SMA-6; Dip all urine. Record fluids - strict INS/OUTS – starting in ER. Admit patient to ICU as soon as possible. TREATMENT OF DKA Objectives: Fluid therapy to restore circulating volume; replace deficits of water, Na and K; and restore GFR to enhance clearance of ketones and glucose. Insulin therapy to suppress lipolysis with ketogenesis, decrease gluconeogenesis and increase glucose uptake. INITIAL MANAGEMENT: Hydration: If the patient’s hemodynamic status appears compromised (shock), a NS (0.9% saline) bolus (10-20 cc/kg) may be given rapidly. If without shock, depending on state of hydration, may give 5-10 cc/kg NS over 1 hr. Acidosis: Use of bicarbonate only considered if pH < 6.90. Discuss with Pediatric Endocrine Attending (Possible dose: 1-2 mEq/kg over 1-2 hr). Do NOT use IV bolus. B. FLUIDS: Calculate specific requirements (See Additional Considerations sections for more detail). Volume: Calculate Deficit + Maintenance and replace evenly over remainder of 48 hrs. Total fluid rate should not exceed 1 1/2 – 2 x maintenance. *** Record Ongoing Losses (i.e. polyuria, vomitus) for subsequent consideration. Eg: Severely ill 30 kg child with DKA and 10% dehydration. Overall deficit 3000cc plus maintenance 70 cc/hr. Received 10 cc/kg/hr X 1 in ER. Deficit 3000cc minus ER 300cc plus maintenance = 4380cc to be given over 47 hr = 93cc/hr. 93 cc/hr minus insulin drip of 30 cc/hr = 63 cc/hr of IVF. Fluid: In practical terms the following sequence of fluids is generally used. This results in a moderate excess of sodium, but is acceptable if the patient does not have cardiac or renal disease or other limitations. Start with NS (0.9% saline). Add Potassium when serum K <5.0 or1-2hrs after fluids and insulin started and recent urination. When K is added may use NS (0.9% saline), ¾ NS (0.67% saline) or ½ NS (0.45% saline). Do not use fluids with osm. less then .45%NS ! When serum glucose < 250-300 mg/dl, add dextrose to ½ NS (0.45% saline) plus K. C. INSULIN TREATMENT: Start IV insulin as soon as diagnosis confirmed and fluid hydration established. IV insulin infusion allows flexibility to change the dose rapidly but needs close supervision. Insulin IV Infusion: Insulin infusion, 0.1 U/kg/hr (50 units of Regular insulin in 500 cc NS (0.9% saline) = 0.1 U/cc. Initial dose 1 cc/kg/hr). Run 50 cc through the IV tubing first. Insulin infusion must be regulated with a pump. Make up fresh solution every 8-12 hrs. Aim to decrease blood sugar by 100 mg/dl/hr. 4. ADDITIONAL CONSIDERATIONS Fluids. NPO except ice chips. Assess fluid INS/OUTS by adding up totals every 4 hours. Inadequate hydration contributes to persistent acidosis; over-hydration may contribute to cerebral edema. Consider replacing deficit more slowly if child < 5 years of age and/or newly diagnosed or severe hyperosmolality. Initial hypernatremia indicates severe dehydration. Rehydrate with extreme caution using NS (0.9% saline). Consider adjusting fluid volume if excessive onging losses (vomiting, polyuria) leading to fluid OUTS > INS.
Potassium.
There is a marked depletion of body K+ in DKA. Add K+ sooner rather than later. Correction of acidosis and treatment with insulin + glucose will cause hypokalemia. If serum K+ < 5.0, and there is history of recent urination and/or ECG without peaked T waves, IV potassium can be started. Generally 30 – 40 mEq K+/L is used in hydrating fluid. A few patients need considerable more K+ as indicated by falling serum K+; increase to 50 or 60 mEq/L. Phosphate. Total body P is depleted in DKA. Benefit of P replacement is unclear. Consider half of potassium given as KCl and half as K phosphate. If P is given, monitor serum calcium levels because risk of hypocalcemia. Bicarbonate. Bicarbonate is not given in DKA treatment except for severe acidosis (pH < 6.9) Sudden correction of serum pH can paradoxically lower CSF pH. Endogenous production of HCO3 occurs with metabolism of ketones. Insulin/Glucose. Consider using lower insulin dose in special situations: infants, new onset diabetes, recent big SC dose of insulin or marked hyperglycemia (>1200).
If no clinical improvement on 0.1 U/kg/hr – reassess insulin infusion flow and constitution and hydrating fluids. Consider increasing cautiously to 0.15-0.20 U/kg/h (e.g. insulin resistance, ongoing infection).
Avoid stopping insulin infusion. Hypoglycemia may be managed with increased IV glucose and temporary decreasing insulin.
Insulin infusion should be continued until pH > 7.3 and/or serum bicarb > 18.
In order to maintain blood glucose at target range of 100-200 mg/dl may need to increase dextrose concentration to 7.5, 10 or 12.5% (limit of peripheral IV). If hydration rate is decreased may need to increase dextrose concentration or decrease insulin infusion.

5. MONITORING AND OBSERVATION.

*** VERY CLOSE OBSERVATION. KEEP FLOW SHEET. STRICT INS/OUTS ***

Over-vigorous management can produce too rapid changes in glucose, osmolality and pH and may contribute to development of complications: hypoglycemia, hypokalemia, hypocalcemia, hypernatremia, fluid overload and hyperchloremic acidosis.

Monitor at least Q 1 hr: vital signs, neurological check, fingerstick glucose. Monitor Q 2 hr: SMA-6 and pH for first 4-8 hours. When improving trend established, decrease frequency to Q 3-4 hrs. Do fingerstick glucose Q 1 hr while on insulin infusion and after any change in rate of IV glucose or insulin. Test all urine for glucose and ketones.
Cerebral edema: *** Cerebral edema occurs in up to 1% of children with DKA and accounts for more then half of the mortality rate. At highest risk are patients who are newly diagnosed and age < 5 years. Monitor sensorium carefully. If any indication of severe headache, increased drowsiness, deepening coma, dilated pupils, ? HR, ? BP, cranial nerve palsy — do complete neurological examination, check for papilledema and reach rapid decision for change in management with attendings. (Consider: Mannitol 0.25-1.0 gm/kg IV over 15-30min, decrease IVF by 50%, elevate head of bed) 6. PROGRESS TO SUBCUTANEOUS INSULIN. When child is stable, alert, ready to eat and biochemical parameters improved (pH > 7.3, serum bicarb > 18) may change from IV to SC insulin. At time of change of insulin -First SC dose of rapid acting insulin should be given 10-45 min before stopping the IV insulin infusion. Insulin doses are individualized for each patient and must be discussed with the Pediatric Endocrinology/Diabetes Team.

When child has eaten, change IV fluid to dextrose free (i.e. 0.45% NS)
Decrease IV fluid rate to adjust for PO fluids. Allow patient to self regulate fluid intake

(Pediatric Diabetes Team/FG 7/03)

Written by reuben

October 25th, 2011 at 5:08 pm

Posted in Peds

Racemic Epinephrine: Floor vs. PICU

Hi everyone,

We wanted to clarify the admission and hospitalization process for patients with croup.

Racemic epinephrine can be given on the floors and does not need to be given in a monitored setting (i.e. the PICU). However, when administered on the floors, the floor team (residents and nurses) should be aware that the patient requires close observation, i.e. frequent checks, after the medicine has been given. These observations need to be documented in the medical record. Any patient who has a declining respiratory status, low oxygen saturation, or worsening hemodynamic status may require closer monitoring. The need for closer monitoring has less to do with the medication administered and more to do with the underlying disease process. A PICU attending may be consulted to assist in this decision.

Also, the amount of racemic epinephrine given in the Emergency Room does not dictate where the patient should be admitted to. The clinical status of the patient is what should determine if the patient goes to the PICU or to the floors. For instance, a patient may receive 2 doses of racemic epinephrine in the Emergency Room, and if they have an appropriate respiratory status for the floor, then they should be admitted to the floor.
If you have any questions or comments, please email me.

Thanks,

Beth Goodman, MD
Pediatric Chief Resident
The Mount Sinai Kravis Children’s Hospital
elizabeth.goodman@mssm.edu

Written by reuben

October 23rd, 2011 at 4:53 pm

Posted in Peds

Pediatric Dental Consults

Bottom Line:

For non-emergent dental patients without insurance accepted by our clinic: refer them up (not a consult) and they would have to pay up front to be seen, or they could go to someone who accepts their insurance.

For emergent dental patients: consult dental and they will come down or have you send the patient up.

Email from Carla Kellner:

The patients are to be sent to dental, and they are to be seen.

I think that there is confusion at the front desk with regard to a consult (needing emergency treatment) vs. a patient that has been discharged (without treatment) to follow up with a dentist. When patients are discharged and sent to us for follow up, we inform patients that we can see them, but that they will have a financial responsibility if they have an insurance that we do not accept, or if they are uninsured. We also provide information for them to complete Medicaid applications, particularly since children are all eligible for insurance. We do not turn away patients, however many patients choose to leave because they do not want the responsibility of a bill.

Thank you,

Carla Kellner
Administrative Director
Department of Dentistry
Mount Sinai Medical Center
(212) 241-5275

Written by reuben

October 15th, 2011 at 5:40 pm

Posted in Dentistry,Peds

Pediatric ED – Medical Legal Info Summary

by Inna Elikashvili

Consent for Treatment
• Consent should be obtained from all patients seen in the ED.
• If Minors = <18yo ? obtain consent from legal guardian unless: • emergency situation and consent would delay treatment • minor is pregnant, married, a parent or emancipated • minor seeking care for medical services they may consent to Minors in NYS can consent to: * Contraceptive Services * Adoptive Services * Prenatal Care * STI Services * Medical Care for Minor’s Child * No law regarding abortion For info on other states: http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf AMA • Parents can sign children out AMA • If MD feels it is not safe, may stop from doing so • Protect yourself: call 911, Risk Management, ACS, Social Work • DOCUMENT !!! Mandated Reporter • MUST REPORT when acting in professional role & presented with reasonable cause to suspect child abuse where a child, parent or other person legally responsible for the child is before the mandated reporter • When not acting in professional duty, not required to report • Cannot be penalized for reporting • If fail to report: o Could be charged with class A misdemeanor o Can be subject to criminal penalties o May be sued in civil court for monetary damages • Parental knowledge of a minor's voluntary sexual activity with a peer is not child abuse and should not be reported to the State Central Register • Statutory rape (minor + person > 18yo) is a crime, but not reportable to ACS

Mandated Reporter (800) 635-1522
Public Hotline (800) 342-3720
http://www.nyc.gov/html/acs

Written by reuben

October 12th, 2011 at 11:13 pm

Posted in Peds

Flocked swab in Hanks Medium

Written by reuben

October 12th, 2011 at 9:28 pm

Posted in Peds

HHC Policy on Taking Pictures of Patients

Written by reuben

October 5th, 2011 at 10:48 pm

If making the diagnosis of HIV

1. JMF has agreed to see all new positives same day (if before noon)
or next day (if afternoon) as a walk-in, no appointment necessary,
they do not need to call. Just put the JMF information on the
discharge paperwork and have them bring to clinic. We are working on
making up appointment cards, these will be kept by social work (see
below).

2. Social work on-call has agreed to come in (yes, come in) for all
new positives. You dont need to do the counseling. You CAN, but dont
need to.

Scott Goldberg

Written by reuben

October 2nd, 2011 at 6:56 pm

Posted in HIV