SimFridays - paediatric DKA

We aim to run simulations every Friday at 11am, see the gmail calendar for the up-to-date schedule. The sim homepage is derriforded.com/sim where you can see our monthly theme and you can submit suggestions for what we should cover!

In September we have covered (click to see the blog summary): 

• Paediatric asthma
• Sepsis in an infant
• Paediatric head injury and safeguarding
• Paediatric diabetic ketoacidosis - see below!

The DKA simulation below was carried out twice and the learning here is a summary of both sessions.

The simulated case: 
Tara is a 10 year old child brought in by a parent. They have been feeling unwell for a few weeks and today they have developed vomiting and pain in their abdomen.

Do you already have key diagnoses in mind? What examinations and selective testing will help you rule options in or out?

​What happened?
Initial assessments noted a child that was vomiting, with tachycardia of 130bpm. Their blood sugar level was around 20mmol/L and blood ketones were high. Neurological observations were recorded. 

The team put in a cannula and took blood for the lab as well as a venous blood gas. They gave an IV fluid bolus and referred to the paediatric team. 

A diagnosis of diabetic ketoacidosis was made.

​What did we think? 
In debrief we discussed:

• Technical
  • The guideline and where to find it - see below. 
  • Neurological observations important in case of developing cerebral oedema.
  • VBGs: for efficiency it’s a good idea to take a capillary blood gas at the same time as the blood sugar level, in case there are delays with obtaining venous access.
• Non-technical
  • Maintaining communication lines by keeping the team leader at the end of the bed where possible. 
  • Remembering to start handovers with the “S” in SBAR. 

We discussed in debrief the latest shift in DKA management, from a previous intention to restrict fluid input due to concern of causing cerebral oedema, to a stance of greater fluid administration. The weight of evidence indicates that cerebral oedema develops out of the disease process itself rather than related to fluid-giving. The local guideline (see below) gives clear instruction of the fluid required in this case. 

We talked through the balance required in keeping the parent informed about what is happening whilst ensuring no delay with immediate care needs. 

We briefly touched upon the PACE model of assertiveness. This blog describes the challenges of speaking up and how PACE can be used to gradually but assertively escalate your concern to a colleague - you can scroll down to where the example of this is given. Here is a case study of it being used by a “junior” colleague to make suggestions to a “senior” during the resuscitation of a child. 

Feedback from the sim participants noted the difficulty for adult-trained nurses to be familiar with the paediatric area and equipment - we can aim to pair a paediatric and adult nurse during scenarios. It was suggested we should have more speech directly from the mannequin - we can aim to do this if a facilitator remains outside of the room in future. 

The guidelines:
On the ED browser page you can find two paeds DKA links - the documentation and an appendix for further information. The documentation link is a complete booklet that allows you to write in your results as it guides you through the process and the calculations. You can take a look at the same document on the British Society for Endocrinology and Diabetes page here. It is a good idea to print this off early in the process so it can guide you. I am going to look into whether we can have a few full-colour versions available.

This guideline was brought out in March 2020 and represents some significant changes on previous versions that are worth being aware of. As mentioned above, the fluid strategy is now more permissive rather than restrictive, with all patients receiving a fluid bolus of 10mL/kg 0.9% saline, with an extra 10mL/kg (i.e. 20mL/kg total) for those in shock (Tasker 2020). Inadequate fluid resuscitation is noted as one of the key contributors to death in DKA resulting from inadequate cerebral perfusion (BDPED).  

Have a look at page 5 (and a little at the top of page 7) of the appendix document, also to be found here. This gives a (virtually) single-page overview of what we need to achieve for these patients in the ED. However when you are looking after a patient with DKA you should use the full guideline above.

Some more detail on this change in guidance, by Dr Tom Siese: 
The latest thinking is that rather than the cerebral injury in DKA being simply related to osmotic shifts due to over-rapid fluid treatment, there is increasing evidence which points towards a state of metabolic acidosis and dehydration which then paves the way for a “hyperinflammatory state”.  The results from the recent randomised controlled PECARN DKA Fluid Trial (Kuppermann et al 2018) supports the return of permissive fluid boluses in paediatric DKA.
 
At time of writing, the latest editorial in the Archives of Disease in Childhood (Tasker 2020) notes caution in treating cases with altered consciousness, as only 2% of study participants in the above trial had a GCS<14.  Therefore the bottom line is don’t be afraid to rehydrate children with DKA, but all cases will still need discussing with a senior member of the paediatric team from an early stage.
​

To do:

If it’s been a while since you worked in the paeds area, ask someone who is regularly there to show you where key items are, and if you have supernumerary time you could spend some of it in paediatrics   [  ]

Have a look at the main guideline document either on our ED browser or via the link above, plus page 5-7 of the appendix document  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


James Keitley - ED sim fellow
On behalf of the faculty behind this sim Hana Bashir, Andy Robinson, Thomas Siese, Rachel Garlick

References:
-  British Society for Paediatric Endocrinology and Diabetes [BSPED]. 2020. Integrated care pathway for the management of children and young people with diabetic ketoacidosis. Available from: https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf. 
-  British Society for Paediatric Endocrinology and Diabetes. 2020. BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. Available from: https://www.sort.nhs.uk/Media/Guidelines/BSPED-DKA-guideline-2020-update.pdf. 
-  Kuppermann et al. 2018. Clinical Trial of fluid infusion rates for paediatric DKA. NEJM; 378:2275-2287. www.nejm.org/doi/full/10.1056/nejmoa1716816  
-  Nickson C. 2019. Speaking Up. LifeInTheFastLane blog. Available from: https://litfl.com/speaking-up/. 
-  Tasker R C. 2020. Fluid Management during DKA in children: guidelines, consensus, recommendations and clinical judgement. ADC; 105: 917-918. pubmed.ncbi.nlm.nih.gov/32847796/
-  Yianni L, Rodd IG236(P) Pace – ‘Probe, Alert, Challenge, Escalate’ Model of Graded Assertiveness Used in Paediatric ResuscitationArchives of Disease in Childhood 2017;102:A93.

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For clinical decisions please refer directly to the guidance. This blog will not be updated.