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I truly believe that Jay has hit it on the head....  PROTECT THAT BRAIN.
 
I once heard a speaker who talked about how he managed DKA (and
Hyperosmolar-non-keytotic-hyperglycemic crisis)
As I recall,  he broke it up into a different stages,  and it was over a
48-72 hour period.  Here is what I can recall...
 
FIRST TWO HOURS
1.)    Insulin IV Bolus based on bedside glucose monitoring
                                    400-450  - NO BOLUS drip at 1 u/hr
                                    451-500  - 2 units regular insulin and
drip at 2 u/hr
                                    501-550  - 3 units regular insulin and
drip at 3 u/hr
                                    551-600  -  4 units regular insulin and
drip at 4u/hr
                                      etc..
                        After the first hour the drip rates were adjusted to
achieve a bedside glucose drop of no more than 25
 
2.)     Fluid was based on total estimated fluid loss.  He was a nut on
weight,  and that children should be weighed naked before any fluid was
started and the weight repeated every 4 hours until the patient was on only
maintenance fluid and the glucose was stable.
          He would bolus only 10-15% of total fluid loss over the first two
hours,  with a maximum of 15cc/kg. He always bolused with NS + 10 KCl until
the lab results were back.  If the Na<145 he kept with NS,  if >145 he used
1/2NS or had the pharmacy mix 1/4NS if Na > 160.
          He would give 50cc of 25% Albumin over 2 hours.  This was started
at the beginning of the second hour.
 
3.)      He would also start to protect the brain early.  He believed in
dexamethazone and would start that as soon as possible.  He also would
consider the starting of mannitol at 1/4 the dose and infuse it very slowly.
He tried to keep U/O a max of  4cc/Kg/Hr.  He would replace U/O greater than
4cc/kg./hr at  1:1,  not to exceed 2% of the total fluid loss.  He would
adjust the mannitol drip to achieve the desired rate.  He did admit that
this was somewhat hard to do and would often just give a bolus (1/4 of
normal recommended dose) over 2 hours and repeat it every 6 hours,  without
replacement.
 
SECOND TWO HOURS
 1.)   Fluid replacement was decreased to 5% of total fluid loss per hour.
(Max of Maintenance + 1/2 Maintenance)
 
NEXT FOUR HOURS
1.)  Fluid replacement was decreased to 2.5% of total fluid loss per hour
.  (Max of Maintenance + 1/2 Maintenance)
 
NEXT FOUR HOURS and until 75% of fluid loss was replaced (don't forget to
factor in losses) (may take up to 72 hours)
1.)   Fluid replacement was kept at 2.5% of total fluid loss with a MAX of
Maintenance + 1/3 Maintenance
 
Now his weight theory.  If the child is loosing weight,  you have to
decrease his losses by decreasing the mannitol, etc..
If the child was gaining weight you needed to increase the mannitol and even
decrease the fluids.  He used a formula to calculate weight loss,  and it
was based on the belief that 2.2Kg's is equal to about 500cc of fluid.  He
used the BSA and Estimated Fluid Loss and the amount of fluid received as
well as output and came up with a number.  I wish I could remember it...  it
was quite interesting.
 
I don't know if this will help,  or if anyone else has heard of this method.
This MD passed away a few years ago,  so I am sorry that I can not find out
the specifics except as I recall them.
 
 
 
Rich Hemmer
[log in to unmask]
 
 
 
 
 
 
-----Original Message-----
From: Jay Pershad, M.D. <[log in to unmask]>
To: Multiple recipients of list PED-EM-L <[log in to unmask]>
Date: Saturday, March 14, 1998 10:51 AM
Subject: Re: DkA
 
 
>Institute "cerebral resuscitation"!!!
>RSI with raised ICP precautions
>Hyperventilate
>Mannitol
>Head elevation
>Confirm "edema" with head CT
>Conservative rehydration with careful attention to fall in measured
>osmolarity ( ?? < 10 mosm/l/24 hours)
>
>AND PRAY!
>
>Jay Pershad
>
>> -----Original Message-----
>> From: Michael Newdow [SMTP:[log in to unmask]]
>> Sent: Friday, March 13, 1998 6:39 PM
>> To:   Jay Pershad, M.D.
>> Subject:      Re: DkA
>>
>> > It is imprtant to be
>> > vigilant all the time for any complaints of HA, worsening lethargy,
>> > blurry vision, or a corrected sodium that does not rise with
>> hydration.
>> > These may be early signs of impending cerebral edema.
>> >
>>
>> What do you do then?
>
>For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
>The URL for the PED-EM-L Web Page is:
>  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>
 
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html