diabetic ketoacidosis in children

1. DIABETIC KETOACIDOSIS IN
CHILDREN
D:MH RADI
SENIOR REGESTRAR OF PEDIATRICS

2. DEFINITION
• Hyperglycemia BG > 200 mg/dl (11 mmol/l)
(young or partially treated children, pregnant adolescents may present with
“euglycemic ketoacidosis”)
• Venous pH <7.3 and/or bicarbonate <15 mmol/L
• mild DKA pH <7.3 bicarbonate <15
• moderate pH <7.2 bicarbonate <10
• severe pH <7.1 bicarbonate < 5
• Glucosuria and ketonuria/ketonemia (β-HOB)

3. INCIDENCE OF DKA AT ONSET
• Wide geographic variation in DKA rates at diabetes
onset: 15 -70%
• More common in developing countries
• DKA rates inversely related to incidence of type 1
diabetes

4. RISK FACTORS FOR DKA AT ONSET
• Age <12 yrs
• No first degree diabetic relative
• Lower socioeconomic status
• High dose glucocorticoids, atypical antipsychotics,
diazoxide and some immunosuppresive drugs
• Poor access to medical care

5. DKA IN CHILDREN WITH ESTABLISHED T1DM
• The risk of DKA varies from 1:10 to 1:100 /p-yr
• Poor metabolic control or previous DKA  risk
• Adolescent girls
• Children with psychiatric disorders, including those
with eating disorders
• Lower socio-economic status
• Inappropriate interruption of insulin pump therapy

6. PROPORTION OF CHILDREN WITH RECURRENT
DKA
0 1 2+
• 60% of DKA episodes
occurred in 5% of
children who had 2 or
more events
# of DKA events
5%

7. Diabetes Care 2006 29:1150-1159

8. SIGNS OF DKA
• Vomiting
• Increased urination
• Abdominal pain
• Fruity odor to breath
• Dry mouth and tongue
• Drowsiness
• Deep breathing
• Coma
• Death

9. PHYSICAL EXAM
• Perfusion
• Vital Signs - including weight
• Hydration
• Mental Status
• Evidence for insulin resistance

10. CEREBRAL EDEMA
• Know what to look for
• Altered mental status/ severe headache
• Recurrence of vomiting
• Changes in pupil size, seizures, bradycardia
• Clinical worsening despite improving lab values
• CT/ MRI changes may not be seen in early cerebral edema

11. TIME OF ONSET OF NEUROLOGICAL COMPROMISE
(HOURS)
0
2
4
6
8
10
12
14
16
0-2.9 3-5.9 6-8.9 9-11.9 12-14.9 >15
# of
patients
Muir A, et al, Diab Care. July 2004
Timing of Onset of Cerebral Edema in DKA

12. CALCULATIONS
SERUM OSMOLALITY:
2[NA+K]+ (GLUCOSE/18) + BUN/2.8
SERUM NA:
CORRECTED NA =
MEASURED NA + (1.6)(GLUCOSE - 100)/100
ANION GAP:
[NA] – ([CL]+[HCO3])
NORMALLY 12+/-2 MMOL/L

13. TREATMENT
• Consider ICU admission for closer monitoring if:
• Severe DKA (pH < 7.1 or < 7.2 in young child)
• Altered level of consciousness
• Under age of 5 years
• Increased risk for cerebral edema
• Caution with meds that may alter mental status

14. TREATMENT
Monitoring
• Management requires close attention to detail
• Use a flowsheet to track vital signs labs, rates of
insulin, fluids, dextrose
• Neurological status
• consider neuro checks q 1 hr
• How does the patient look TO YOU?
• Assess, reassess and then assess again

15. FLUID THERAPY FOR DKA
• Assume 10-15% dehydration
• Begin with a 10-20 ml/kg bolus of NS
• Replace calculated deficit evenly over 36-48
hours
• Do not exceed 40ml’s/kg in the initial 4 hours, or
4 L/m squared in 24 hours

16. DKA - FLUIDS
• START BY ½ NS
• K supplementation
20mEq/L K Acetate + 20mEq/L K Phosphate
• Ionized calcium is low, phosphorous should not be given
• early replacement and frequent monitoring
• Bicarbonate therapy is rarely, if ever, indicated

17. INSULIN THERAPY FOR DKA
• IV infusion with basal rate 0.1 U/kg/hr
• No initial insulin bolus – it will decrease time to correction of the
glucose, but does not alter the time to correction of acidosis
It may decrease the serum osmolality more rapidly than desirable
• Ideal glucose decline is about 100 mg%/hr
• Continue insulin until urinary (blood) ketones are cleared

18. POTASSIUM
• Add potassium when K< 5 and with urination
• K >5.5 – no potassium in IVF
• K 4.5 – 5.5 – 20 meq/L K+
• K <4.5 – 40 meq/L K+

19. USE OF BICARBONATE IN DKA
• Bicarbonate should be used only when
there is severe depression of the
circulatory system or cellular metabolism...
• Not recommended unless pH <7.0, not even then, unless above true

20. TREATMENT OF CEREBRAL EDEMA
• Mannitol: 1 gram/ kg IV over 30 minutes
• Elevate the head of the bed
• Decrease IVF rate and insulin infusion rate
• Pediatric ICU management
• Do not delay treatment until radiographic evidence

21. SUCCESSFUL MANAGEMENT
• Careful attention to detail
• Careful record keeping
• A detailed flow chart is essential
• Following the data recorded is also essential
• Repeated examination of the patient

22. THANK YOU