Pediatric Diabetic Ketoacidosis Workup

  • Author: Grace M Young, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Mar 9, 2012
 

Laboratory Studies

  • Serum glucose: Serum glucose (eg, Accu-Chek, Dextrostix) determination of hyperglycemia provides the opportunity for rapid diagnosis and treatment of diabetic ketoacidosis (DKA). However, a urine analysis (dip for sugar and ketones) is also acceptable.
  • Serum potassium level
    • This is the most important electrolyte disturbance in patients with severe diabetic ketoacidosis.
    • A patient with a low serum potassium level should be assumed to have a potentially life-threatening total body potassium level.
    • Patients with evidence of hypovolemia or history of polydipsia who have normal or high serum potassium level should be assumed to have moderate total potassium depletion.
    • Therapy should begin with volume resuscitation.
    • As a result of the potential for hypokalemia-induced malignant dysrhythmias, do not give insulin to patients known to have profound potassium depletion until potassium replenishment is underway.
  • ABG level
    • Venous blood gases are an alternative and may be kinder for patients.
    • Historically, venous pH has been believed to overestimate the degree of acidosis because of decreased intravascular volume and increased peripheral lactic acidosis. However, an adult study of patients with diabetic ketoacidosis concluded that venous blood gases accurately demonstrated the degree of acidosis.
  • Other studies: Obtain serum sodium, chloride, bicarbonate, BUN, creatinine, magnesium, calcium, and phosphate levels.
  • Glycosylated hemoglobin: In a patient with known diabetes, high percentages of glycosylated hemoglobin (Hgb A1C) indicate poor compliance with insulin therapy.
  • CBC count: Note that an increased WBC count may be a response to stress in diabetic ketoacidosis and not necessarily a sign of infection.
  • Urine glucose, ketones, and osmolality
  • Serum osmolality
  • Blood, urine, and throat cultures
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Imaging Studies

  • Obtain studies appropriate for suspected infection, obstructive abdominal processes, or cerebral edema.
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Other Tests

  • Electrocardiography
    • An ECG is especially helpful when results of serum potassium concentration are not rapidly available.
    • Hyperkalemia causes peaked T waves and cardiac dysrhythmias.
  • Any studies appropriate for suspected infections, toxidromes, or other metabolic abnormalities
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Procedures

  • Establish 2 large intravenous catheter lines for fluids, insulin infusion, drips, and further venous sampling (use distal isolated dedicated saline lock for the latter purpose, which is kinder to patients).
  • Arterial catheterization if the following conditions are present:
    • Profoundly altered mental status
    • Signs of severe shock
    • Signs of severe acidosis
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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.

Specialty Editor Board

James Li, MD  Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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.

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  Associate 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: Nothing to disclose.

References

  1. Kisiel M, Marsons L. Recognizing and responding to hyperglycaemic emergencies. Br J Nurs. Oct 8-21 2009;18(18):1094-8. [Medline].

  2. 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].

  3. Tiwari LK, Muralindharan J, Singhi S. Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: Role of fluid refractory shock*. Pediatr Crit Care Med. Mar 2012;13(2):e91-6. [Medline].

  4. Bui H, To T, Stein R, Fung K, Daneman D. Is Diabetic Ketoacidosis at Disease Onset a Result of Missed Diagnosis?. J Pediatr. Dec 2 2009;[Medline].

  5. [Guideline] Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care. Jan 2004;27 Suppl 1:S94-102. [Medline].

  6. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. Dec 2010;1(2):103-20. [Medline]. [Full Text].

  7. Kapellen T, Vogel C, Telleis D, Siekmeyer M, Kiess W. Treatment of Diabetic Ketoacidosis (DKA) with 2 Different Regimens Regarding Fluid Substitution and Insulin Dosage (0.025 vs. 0.1?units/kg/h). Exp Clin Endocrinol Diabetes. Feb 10 2012;[Medline].

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

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

  10. 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].

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

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

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

  14. 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].

  15. 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].

  16. 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].

  17. 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].

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

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. 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].

  26. 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].

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

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

  33. 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].

  34. 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].

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

  36. 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].

  37. 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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Sample diabetic ketoacidosis flow sheet.
 
 
 
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