eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Diabetic Ketoacidosis: Follow-up

Author: Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Contributor Information and Disclosures

Updated: Jun 16, 2008

Follow-up

Further Inpatient Care

  • Admit children with diabetic ketoacidosis (DKA) for further evaluation, observation, management, diabetes education, and assessment of compliance by responsible caretakers.
  • Assess the need for social service intervention.

Transfer

  • Transfer to a pediatric intensive care unit is prudent for the patient with persistent altered mental status, resistant acidosis, and hemodynamic instability, and for the first-time newly diagnosed patient.

Deterrence/Prevention

  • If the patient is known to have diabetes, maintain compliance with an insulin therapy regimen and close contact with the treating physician. This is especially important in the presence of nausea, vomiting, and abdominal pain.

Complications

  • Cerebral edema
    • Cerebral edema occurs in 0.7-1% of children with DKA.
    • Causes are multifactorial but may include too-rapid infusion of fluids and electrolytes, overhydration, and overly aggressive correction of acidosis or hyperglycemia.
    • Treatment includes intubation, hyperventilation, and mannitol 0.25-1 g/kg intravenously.
  • Hypoglycemia
    • Causes include increased sensitivity to exogenous insulin and insufficient serum glucose for insulin to metabolize.
    • Treatment includes adding 5-10% dextrose to intravenous fluids when serum glucose level is 250-300 mg/dL.
  • Hypokalemia
    • Serum potassium begins to reflect actual total body potassium depletion as volume depletion and acidosis resolve.
    • Add potassium to intravenous fluids (see Emergency Department Care) when urine output is present and results of serum potassium level are available.
  • Cardiac dysrhythmia
    • Causes include hyperkalemia, hypokalemia, and hypocalcemia.
    • Treatment involves correcting the specific cause.
  • Pulmonary edema
    • Causes include low plasma oncotic pressure and increased pulmonary capillary permeability.
    • Treatment includes oxygen and diuresis.

Prognosis

  • The prognosis is excellent if aggressive fluid and insulin therapy commence in the first few hours of diagnosis.

Miscellaneous

Medicolegal Pitfalls

  • Overreliance on a serum glucose level greater than 350 to diagnose diabetic ketoacidosis (DKA)
  • Failure to diagnose DKA or its complications
  • Lack of vigilance with regard to electrolyte shifts
  • Failure to diagnose underlying infection or other precipitating event
  • Aggressive insulin therapy before correction of potassium
  • Failure to provide adequate potassium replacement in the potassium-depleted patient

Special Concerns

  • The pregnant patient with gestational diabetes should be treated in consultation with a pediatric endocrinologist and obstetrician.
 


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References
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References

  1. Wolfsdorf J, Glaser N, Sperling MA; American Diabetes Association. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. May 2006;29(5):1150-9. [Medline].

  2. Ackerman A. Cerebral edema in pediatric diabetic ketoacidosis: Can six patients make a difference?. Crit Care Med. Aug 2006;34(8):2258-9. [Medline].

  3. Agus MS, Wolfsdorf JI. Diabetic ketoacidosis in children. Pediatr Clin North Am. Aug 2005;52(4):1147-63, ix. [Medline].

  4. Alawi KA, Morrison GC, Fraser DD, Al-Farsi S, Collier C, Kornecki A. Insulin infusion via an intraosseous needle in diabetic ketoacidosis. Anaesth Intensive Care. Jan 2008;36(1):110-2. [Medline].

  5. Bismuth E, Laffel L. Can we prevent diabetic ketoacidosis in children?. Pediatr Diabetes. Oct 2007;8 Suppl 6:24-33. [Medline].

  6. Cardella F. Insulin therapy during diabetic ketoacidosis in children. Acta Biomed Ateneo Parmense. 2005;76 Suppl 3:49-54. [Medline].

  7. Cody D. Infant and toddler diabetes. Arch Dis Child. Aug 2007;92(8):716-9. [Medline].

  8. Dunger DB, Sperling MA, Acerini CL, et al. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child. Feb 2004;89(2):188-94. [Medline].

  9. Dunger DB, Sperling MA, Acerini CL, et al. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. Feb 2004;113(2):e133-40. [Medline].

  10. Edge JA, Hawkins MM, Winter DL, Dunger DB. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child. Jul 2001;85(1):16-22. [Medline].

  11. Fiordalisi I, Novotny WE, Holbert D, Finberg L, Harris GD. An 18-yr prospective study of pediatric diabetic ketoacidosis: an approach to minimizing the risk of brain herniation during treatment. Pediatr Diabetes. Jun 2007;8(3):142-9. [Medline].

  12. Friedman AL. Choosing the right fluid and electrolytes prescription in diabetic ketoacidosis. J Pediatr. May 2007;150(5):455-6. [Medline].

  13. Glaser N. New perspectives on the pathogenesis of cerebral edema complicating diabetic ketoacidosis in children. Pediatr Endocrinol Rev. Jun 2006;3(4):379-86. [Medline].

  14. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. Jan 25 2001;344(4):264-9. [Medline].

  15. Glaser N, Kuppermann N. DKA-related cerebral edema and intravenous fluid therapy: potential pitfalls of uncontrolled retrospective studies. J Pediatr. Jan 2008;152(1):145; author reply 147-9. [Medline].

  16. Glaser N, Kuppermann N. The evaluation and management of children with diabetic ketoacidosis in the emergency department. Pediatr Emerg Care. Jul 2004;20(7):477-81; quiz 482-4. [Medline].

  17. Glaser NS, Wootton-Gorges SL, Buonocore MH, et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. Apr 2006;7(2):75-80. [Medline].

  18. Green SM, Rothrock SG, Ho JD, et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. Jan 1998;31(1):41-8. [Medline].

  19. Hanas R, Lindgren F, Lindblad B. Diabetic ketoacidosis and cerebral oedema in Sweden--a 2-year paediatric population study. Diabet Med. Oct 2007;24(10):1080-5. [Medline].

  20. Hoorn EJ, Carlotti AP, Costa LA, MacMahon B, Bohn G, Zietse R, et al. Preventing a drop in effective plasma osmolality to minimize the likelihood of cerebral edema during treatment of children with diabetic ketoacidosis. J Pediatr. May 2007;150(5):467-73. [Medline].

  21. Lawson M. Predictors of acute complications in children with type I diabetes. J Pediatr. Nov 2002;141(5):739-40. [Medline].

  22. Mahmud FH, Ramsay DA, Levin SD, Singh RN, Kotylak T, Fraser DD. Coma with diffuse white matter hemorrhages in juvenile diabetic ketoacidosis. Pediatrics. Dec 2007;120(6):e1540-6. [Medline].

  23. Marcin JP, Glaser N, Barnett P, et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. Dec 2002;141(6):793-7. [Medline].

  24. Munk MD. Pediatric DKA. The presentation, assessment & prehospital management of diabetic ketoacidosis in children. JEMS. Jun 2006;31(6):70-72, 74-80, 82; quiz 84. [Medline].

  25. Noyes KJ, Crofton P, Bath LE, Holmes A, Stark L, Oxley CD, et al. Hydroxybutyrate near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatr Diabetes. Jun 2007;8(3):150-6. [Medline].

  26. Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA. May 15 2002;287(19):2511-8. [Medline].

  27. Rosenbloom AL. Treatment of diabetic ketoacidosis and the risk of cerebral edema. J Pediatr. Jan 2008;152(1):146-7; author reply 147-9. [Medline].

  28. Sema A, Puliyel JM. Cerebral edema in diabetic ketoacidosis with serum sodium <135 mEq/L. J Pediatr. Jan 2008;152(1):145-6; author reply 147-9. [Medline].

  29. Shastry RM, Bhatia V. Cerebral edema in diabetic ketoacidosis. Indian Pediatr. Aug 2006;43(8):701-8. [Medline].

  30. Takaya J, Ohashi R, Harada Y, Yamato F, Higashino H, Kobayashi Y, et al. Cerebral edema in a child with diabetic ketoacidosis before initial treatment. Pediatr Int. Jun 2007;49(3):395-6. [Medline].

  31. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, et al. Diabetic ketoacidosis. Pediatr Diabetes. Feb 2007;8(1):28-43. [Medline].

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Further Reading

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Keywords

diabetic ketoacidosis, DKA, hyperglycemia, ketosis, acidosis, ketone bodies, diabetes, type 1 diabetes mellitus, type 2 diabetes mellitus, insulin deficiency, diabetic ketoacidosis in children, lactic acidosis, hypokalemia, cerebral edema

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Contributor Information and Disclosures

Author

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

James Li, MD, Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: none None None

 
 
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