DR.RAVI DEPT OF PEDIATRICS MGMCRI

1. DIABETIC
KETOACIDOSIS
DR RAVIKUMAR 1ST YEAR PG
PEDIATRICS
MGMCRI

2. TABLE OF CONTENTS
• DEFINITION
• CLINICAL SIGNS
• RISK FACTORS
• PATHOPHYSIOLOGY
• MANAGEMENT
• COMPLICATIONS OF THERAPY
• DDX

3. DEFINITION
THE BIOCHEMICAL CRITERIA FOR THE DIAGNOSIS OF DKA ARE
• Hyperglycemia [BG >11 mmol/L (≈200 mg/dL)]
• Venous Ph<7.3 Or Bicarbonate <15 mmol/L
• Ketonemia And Ketonuria.
THE SEVERITY OF DKA IS CATEGORIZED BY THE DEGREE OF ACIDOSIS :
• Mild: Venous Ph<7.3 Or Bicarbonate <15 mmol/L
• Moderate: Ph<7.2, Bicarbonate <10 mmol/L
• Severe: Ph<7.1, Bicarbonate <5 mmol/L.

4. CLINICAL SIGNS
• Dehydration (Which May Be Difficult
To Detect)
• Tachycardia
• Tachypnea (Which May Be Mistaken
For Pneumonia Or Asthma)
• Deep, Sighing (Kussmaul)
Respiration; Breath Has The
• Smell Of Acetone (Variously
Described As The Odor Of Nail Polish
Remover Or Rotten Fruit)
• Nausea, Vomiting (Which May Be
Mistaken For Gastroenteritis)
• Abdominal Pain That May Mimic An
Acute Abdominal Condition
• Confusion, Drowsiness, Progressive
Reduction In Level Of Consciousness
And, Eventually, Loss Of
Consciousness.

5. CLINICAL MANIFESTATION

6. RISK FACTORS
In Newly Diagnosed Cases :
• Children <2 Years Of Age
• Delayed Diagnosis
• Low Socio-economic Status
• Countries With Low Prevalence Of
Type 1 DM
In Patients With Known Diabetes
• Insulin Omission
• Poor Metabolic Control
• Previous Episode Of DKA
• Psychiatric Disorders
• Failures In Pump Therapy

7. PATHOPHYSIOLOGY

8. MANAGEMENT
EMERGENCY ASSESSMENT
• Immediate Measurement Of BG, Blood Or Urine Ketones, Serum Electrolytes,
Blood Gases And Full Blood Count;
• Assessment Of Severity Of Dehydration And Level Of Consciousness
• A Second Peripheral IV Catheter Should Be Inserted
METICULOUS MONITORING OF
• Hourly Heart Rate, Respiratory Rate, Blood Pressure, Spo2, Fluid Input/Output,
GCS Or AVPU Scale.
• Monitor For Warning Signs
INVESTIGATION
• Hourly CBG (BSL)
• VBG, Sr. Electrolytes Q2H for first 12hrs and then as required

9. MANAGEMENT
STEPS
1. Intravenous Rehydration
2. Acidosis & Bicarbonate Therapy
3. Potassium Replacement
4. Insulin Infusion
5. Sodium Replacement
6. Treat Precipitating Infection, If Present
7. Oral Fluids
8. Stop Of Insulin Infusion

10. MANAGEMENT
FLUIDS & SALT REPLACEMENT
• Initial Fluid :
Severely Volume Depleted But Not In Shock, Volume Expansion (Resuscitation)
Should Begin Immediately With 0.9% Saline 10-20 ml/kg over 1 hour To Restore
The Peripheral Circulation.
• Subsequent Fluid :
IVF 0.9 % NS for Atleast 4-6 hours , Later to 0.45% NS with KCL
48 Hrs Maintenance + Deficit – Bolus (Resuscitation Fluid Already Given) Divided
By 48
• Corrected Sodium levels Rises as BGL fall during Treatment, if not then continue
0.9% NS
Measured Na + 2 {(plasma glucose – 100) divided by 100} mg/dL

11. INSULIN THERAPY
• Begin with Regular Insulin 0.05–0.1 U/kg/h 1–2 h after starting fluid
replacement therapy
• Preparation : Dilute 50 U of Regular Insulin in 50 ml of NS (1Unit = 1ml)
• Titration :
Accepted fall in BSL of 100mg/dl/hr
Adjust Insulin Infusion rate or Dextrose infusion rate to keep BSL between 100 to
200 mg/dl
If BSL < 100mg/dl - Increase Insulin Infusion rate by 50%
If BSL >100mg/dl - Decrease Insulin Infusion rate by 50%
• If BSL <300mg/dl change IVF to 0.45% NS or 5% DNS

12. ISPAD (2014) ALGORITHM

13. ISPAD (2014) ALGORITHM

14. COMPLICATIONS OF THERAPY
1. CEREBRAL EDEMA
• Clinically Significant Cerebral Edema Usually Develops within The First 12 Hr
After Treatment Has Started, But Can Occur Before Treatment Has Begun. Rarely,
May Develop As Late As 24–48 Hrs After The Start Of Treatment
SIGNS AND SYMPTOMS INCLUDE:
• Headache And Slowing Of Heart Rate
• Change In Neurological Status (Restlessness, Irritability, Increased Drowsiness,
And Incontinence)
• Specific Neurological Signs (E.G., Cranial Nerve Palsies, Papilledema)
• Rising Blood Pressure
• Decreased O2 Saturation

15. COMPLICATIONS OF THERAPY
TREATEMENT OF CEREBRAL EDEMA
• Reduce The Rate Of Fluid Administration By One-third.
• Give Mannitol, 0.5–1 g/Kg IV Over 10–15 Min, And Repeat If There Is No Initial
Response In 30 Min To 2 H
• Hypertonic Saline (3%), Suggested Dose 2.5–5 ml/Kg Over 10–15 Min, May Be
Used As An Alternative To Mannitol, Especially If There Is No Initial Response To
Mannitol
Other:
2. INADEQUATE REHYDRATION
3. HYPOGLYCEMIA
4. HYPOKALEMIA
5. HYPERCHLOREMIC ACIDOSIS

16. DDX
HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)

17. MANAGEMENT
GOALS OF THERAPY
• Correct Dehydration,
• Correct Acidosis And Reverse Ketosis,
• Slowly Correct Hyper osmolality And Restore BG To Near Normal,
• Monitor For Complications Of DKA And Its Treatment,
• Identify And Treat Any Precipitating Event.