This document defines diabetic ketoacidosis (DKA) and discusses its incidence, risk factors, signs, and treatment in children. DKA is characterized by hyperglycemia, acidosis, and ketosis. The risk of DKA is higher in children under 12, those with lower socioeconomic status or no family history of diabetes. Recurrent DKA occurs in 5% of children and accounts for 60% of DKA cases. Treatment involves fluid resuscitation, insulin therapy, electrolyte replacement, and close monitoring for cerebral edema, with consideration of ICU admission for severe cases. Successful management requires attention to detail, documentation, and repeated patient examination.

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