eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Diabetic Ketoacidosis: Differential Diagnoses & Workup

Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK
Contributor Information and Disclosures

Updated: Dec 11, 2008

Differential Diagnoses

Acidosis, Metabolic
Respiratory Distress Syndrome
Acidosis, Respiratory
Toxicity, Salicylate
Asthma
Hypokalemia
Pneumonia

Other Problems to Be Considered

Acute abdomen
Gastroenteritis
Hyperosmolar hyperglycemic nonketotic coma (HONK)

Workup

Laboratory Studies

The following studies are indicated in patients with diabetic ketoacidosis (DKA)

  • Blood glucose
    • Capillary blood samples analyzed on any modern blood glucose meter are acceptable for monitoring changes in blood glucose levels as treatment progresses, but measure at least one whole blood glucose at presentation.
    • Check blood glucose at least hourly (more frequently if blood glucose levels fall quickly) or if changes to insulin infusion rates are made.
  • Blood gases
    • Traditionally, arterial blood samples are used; however, free-flowing capillary or venous samples are as reliable for monitoring acidosis are much easier to collect and less traumatic for the child.27
    • Severity of diabetic ketoacidosis can be defined by blood gas results, as follows:
      • Mild diabetic ketoacidosis: pH level of less than 7.3, bicarbonate level of less than 15 mmol/L
      • Moderate diabetic ketoacidosis: pH level of less than 7.2, bicarbonate level of less than 10 mmol/L 
      • Severe diabetic ketoacidosis: pH level of less than 7.1, bicarbonate level of less than 5 mmol/L
  • Potassium
    • Initial blood levels are usually normal or high, despite considerable deficits of total body potassium. This is because the acidosis encourages leakage of intracellular potassium. Insulin drives potassium back into the cells, and levels may drop very quickly with treatment.
    • Frequent (ie, every 1-2 h) checks of potassium levels together with ECG monitoring may be required in the first hours of therapy.
  • Sodium
    • Measured values are likely to be low because of the dilutional effect of hyperglycemia.
    • True sodium levels can be calculated by adding 1.6 mEq/L sodium for every 100 mg/dL glucose (ie, 1 mmol/L sodium for 3 mmol/L glucose).
    • Sodium levels should rise with treatment.
    • Failure of sodium levels to rise is associated with an increased risk of cerebral edema.
  • Blood urea and creatinine: Some creatinine assays can be affected by the presence of ketones, thus giving falsely elevated results. Under these circumstances, blood urea may give a better measure of dehydration.
  • Bicarbonate (usually available from blood gas analysis): This reflects the degree of acidosis.
  • Capillary blood ketone: This can be measured using a handheld meter and are always elevated at presentation of diabetic ketoacidosis (>2 mmol/L). Two studies have proposed using serial measurements as a way of indicating resolution of diabetic ketoacidosis when the pH level is more than 7.3 and the sequential capillary blood ketone level is less than 1 mmol/L.28,29
  • High glycosylated hemoglobin (HbA1c): High results are expected in a patient with newly diagnosed diabetes and in patients with an established diagnosis who have poor compliance to treatment.
  • Full blood count: WBC is usually elevated, even in absence of infection.
  • Urine: Check all urine for glucose and ketones for at least 24 hours particularly if capillary blood ketones are not available.
  • Insulin: This test is especially indicated in children with recurrent diabetic ketoacidosis, as an absence of measurable insulin can confirm omission. Caution is needed because not all assays measure the newer analogue insulins, and insulin antibody levels can also affect the result.
  • Culture: Perform blood culture and other cultures as clinically indicated (eg, urine, throat swab).
  • Amylase: Blood amylase levels often are elevated in diabetic ketoacidosis and can be misleading in the presence of abdominal pain.
  • Serum osmolarity: This is usually elevated.
  • Phosphate, calcium, and magnesium: These levels are invariably reduced but without obvious clinical significance.
  • Lipids: Extremely high triglyceride levels are sometimes present. This causes an artificial lowering of other blood values such as glucose, sodium, and potassium.

Imaging Studies

  • Perform head CT scanning if coma is present or develops. Concurrently, initiate appropriate measures to manage cerebral edema.
  • Perform chest radiography if clinically indicated.

Other Tests

  • ECG is a useful adjunct to monitor potassium status. Characteristic changes appear with extremes of potassium status.
  • Characteristic changes of hypokalemia as represented on ECG (see Media file 1) are as follows:
    • Apparent prolongation of QT interval
    • ST segment depression
    • Flat or diphasic T waves
    • Prominent U waves
    • Prolongation of PR interval
    • Sinoatrial block
  • Hyperkalemia may develop due to overcorrection of potassium loss, with ECG changes as follows (see Media file 2):
    • Broadening of the QRS
    • Peaked T waves
    • Prolonged PR interval
    • Disappearance of P wave
    • Diphasic QRS complex
    • Asystole
  • Regularly assess consciousness level.
    • Check consciousness level hourly for up to 12 hours, especially in a young child with a first presentation of diabetes. The Glasgow coma scale (see Media file 3) is recommended for this purpose.
    • Normal maximum score on the Glasgow coma scale is 15. A score of 12 or less implies significant impairment of consciousness. A falling score may signify development of cerebral edema.

Procedures

  • Ideally, insert a good-sized venous cannula into each arm, the first for fluid, electrolyte, and insulin replacement and the second for regular sampling.
  • Arterial cannulation is appropriate for patients who require mechanical ventilation or for those who need intensive care for conditions such as coma, shock, or severe acidosis.
  • Insert a nasogastric tube and aspirate gastric contents for all patients with impaired consciousness and for children with repeated vomiting.
  • Consider urinary catheterization for children with impaired consciousness. This allows accurate calculation of urinary losses, particularly in the early hyperosmolar phases of diabetic ketoacidosis in which osmotic diuresis can lead to massive urinary losses, even in the presence of dehydration.
  • Manage cerebral edema with intubation and mechanical ventilation in addition to osmotic diuresis.

More on Diabetic Ketoacidosis

Overview: Diabetic Ketoacidosis
Differential Diagnoses & Workup: Diabetic Ketoacidosis
Treatment & Medication: Diabetic Ketoacidosis
Follow-up: Diabetic Ketoacidosis
Multimedia: Diabetic Ketoacidosis
References
[ CLOSE WINDOW ]

References

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

  2. Marshall SM, Walker M, Alberti KGMM. Diabetic Ketoacidosis and Hyperglycaemic non-ketotic coma. In: Alberti, Zimmet, Defronzo eds. International Textbook of Diabetes Mellitus. 1997:1215-30.

  3. Rewers A, Klingensmith G, Davis C, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics. May 2008;121(5):e1258-66. [Medline].

  4. Smith CP, Firth D, Bennett S, et al. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr. May 1998;87(5):537-41. [Medline].

  5. 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].

  6. Levy-Marchal C, Patterson CC, Green A. Geographical variation of presentation at diagnosis of type I diabetes in children: the EURODIAB study. European and Dibetes. Diabetologia. Oct 2001;44 Suppl 3:B75-80. [Medline].

  7. Edge JA, Dunger DB. Variations in the management of diabetic ketoacidosis in children. Diabet Med. Dec 1994;11(10):984-6. [Medline].

  8. Edge JA, Ford-Adams ME, Dunger DB, et al. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. Oct 1999;81(4):318-23. [Medline]. [Full Text].

  9. Neu A, Willasch A, Ehehalt S, et al. Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation. Pediatr Diabetes. Jun 2003;4(2):77-81. [Medline].

  10. Warner DP, McKinney PA, Law GR, Bodansky HJ. Mortality and diabetes from a population based register in Yorkshire 1978-93. Arch Dis Child. May 1998;78(5):435-8. [Medline]. [Full Text].

  11. Durr JA, Hoffman WH, Sklar AH, et al. Correlates of brain edema in uncontrolled IDDM. Diabetes. May 1992;41(5):627-32. [Medline].

  12. Hale PM, Rezvani I, Braunstein AW, et al. Factors predicting cerebral edema in young children with diabetic ketoacidosis and new onset type I diabetes. Acta Paediatr. Jun 1997;86(6):626-31. [Medline].

  13. Mel JM, Werther GA. Incidence and outcome of diabetic cerebral oedema in childhood: are there predictors?. J Paediatr Child Health. Feb 1995;31(1):17-20. [Medline].

  14. Silver SM, Clark EC, Schroeder BM, Sterns RH. Pathogenesis of cerebral edema after treatment of diabetic ketoacidosis [published erratum appears in Kidney Int 1997 May;51(5):1662]. Kidney Int. Apr 1997;51(4):1237-44. [Medline].

  15. Okuda Y, Adrogue HJ, Field JB, et al. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. Jan 1996;81(1):314-20. [Medline].

  16. Hoffman WH, Locksmith JP, Burton EM, et al. Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis. J Diabetes Complications. Nov-Dec 1998;12(6):314-20. [Medline].

  17. Holsclaw DS Jr, Torcato B. Acute pulmonary edema in juvenile diabetic ketoacidosis. Pediatr Pulmonol. Dec 1997;24(6):438-43. [Medline].

  18. Delamater AM, Shaw KH, Applegate EB, et al. Risk for metabolic control problems in minority youth with diabetes. Diabetes Care. May 1999;22(5):700-5. [Medline]. [Full Text].

  19. Cohn BA, Cirillo PM, Wingard DL, et al. Gender differences in hospitalizations for IDDM among adolescents in California, 1991. Implications for prevention. Diabetes Care. Nov 1997;20(11):1677-82. [Medline].

  20. Quinn M, Fleischman A, Rosner B, et al. Characteristics at diagnosis of type 1 diabetes in children younger than 6 years. J Pediatr. Mar 2006;148(3):366-71. [Medline].

  21. Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes. Feb 2006;7(1):11-5. [Medline].

  22. Musey VC, Lee JK, Crawford R. Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis. Diabetes Care. Apr 1995;18(4):483-9. [Medline].

  23. Thompson CJ, Cummings F, Chalmers J, Newton RW. Abnormal insulin treatment behaviour: a major cause of ketoacidosis in the young adult. Diabet Med. May 1995;12(5):429-32. [Medline].

  24. Morris AD, Boyle DI, McMahon AD, et al. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland. Medicines Monitoring Unit. Lancet. Nov 22 1997;350(9090):1505-10. [Medline].

  25. Smaldone A, Honig J, Stone PW, et al. Characteristics of California children with single versus multiple diabetic ketoacidosis hospitalizations (1998-2000). Diabetes Care. Aug 2005;28(8):2082-4. [Medline]. [Full Text].

  26. Holstein A, Abel C, Zumwalde I. Recurrent severe diabetic ketoacidosis due to intoxication with synthetic drugs ('Ecstasy' and 'Speed'). Intensivmedizin und Notfallmedizin. 1997;34(1):46-50.

  27. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. Apr 1998;31(4):459-65. [Medline].

  28. Wiggam MI, O'Kane MJ, Harper R, et al. Treatment of diabetic ketoacidosis using normalization of blood 3- hydroxybutyrate concentration as the endpoint of emergency management. A randomized controlled study. Diabetes Care. Sep 1997;20(9):1347-52. [Medline].

  29. Noyes KJ, Crofton P, Bath LE, 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].

  30. 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].

  31. Harris GD, Fiordalisi I. Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes. Arch Pediatr Adolesc Med. Oct 1994;148(10):1046-52. [Medline].

  32. Butkiewicz EK, Leibson CL, O'Brien PC, Palumbo PJ, Rizza RA. Insulin therapy for diabetic ketoacidosis. Bolus insulin injection versus continuous insulin infusion. Diabetes Care. Aug 1995;18(8):1187-90. [Medline].

  33. [Best Evidence] Della Manna T, Steinmetz L, Campos PR, Farhat SC, Schvartsman C, Kuperman H. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. Aug 2005;28(8):1856-61. [Medline].

  34. 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].

  35. Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). Oct 20 1984;289(6451):1035-8. [Medline].

  36. Vanelli M, Chiari G, Ghizzoni L, et al. Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices. Diabetes Care. Jan 1999;22(1):7-9. [Medline]. [Full Text].

  37. Miller SG. Family therapy for recurrent diabetic ketoacidosis: Treatment guidelines. Family Systems Medicine. 1996;14(3):303-14.

  38. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care. Jul 2004;27(7):1541-6. [Medline].

  39. White H, Cook D, Venkatesh B. The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury. Anesth Analg. Jun 2006;102(6):1836-46. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

diabetic ketoacidosis, DKA, cerebral edema, DKA, diabetes, diabetes mellitus, insulin deficiency, hyperglycemia, low bicarbonate, acidosis, ketonemia, ketonuria, type 1 diabetes, type 1 diabetes mellitus, insulin-dependent diabetes, IDD, insulin-dependent diabetes mellitus, IDDM, childhood diabetes, childhood diabetes mellitus, childhood-onset diabetes, childhood-onset diabetes mellitus, diabetes in childhood, diabetes mellitus in childhood, juvenile-onset diabetes, juvenile-onset diabetes mellitus, ketosis-prone diabetes, autoimmune diabetes mellitus, brittle diabetes mellitus, maturity-onset diabetes of the young, MODY, chamber-pot dropsy, thirst disease, sugar disease, sugar sickness, hypokalemia, hypoglycemia, hyponatremia, acute respiratory distress syndrome, ARDS, pneumothorax, rhabdomyolysis, acute renal failure

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK
William H Lamb, MBBS, MD, FRCP(Edin), FRCP is a member of the following medical societies: British Medical Association, Royal College of Paediatrics and Child Health, and Royal College of Physicians
Disclosure: Medtronic UK Honoraria Speaking and teaching

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.