Approach Considerations
In patients with diabetic ketoacidosis, the first principals of resuscitation apply (ie, the ABCs [airway, breathing, circulation]). [4] Outcomes are best when children are closely monitored and a changing status is promptly addressed. [3, 44] Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose by clinical history, physical signs, and elevated blood glucose.
Fluid, insulin, and electrolyte (potassium and, in select cases, bicarbonate) replacement is essential in the treatment of diabetic ketoacidosis.
Early in the treatment of diabetic ketoacidosis, when blood glucose levels are very elevated, the child can continue to experience massive fluid losses and deteriorate. Strict measurement of fluid balance is essential for optimal treatment.
Continuous subcutaneous insulin infusion therapy using an insulin pump should be stopped during the treatment of diabetic ketoacidosis.
Inpatient care
Children with severe acidosis (ie, pH < 7.1) or with altered consciousness should be admitted to a pediatric intensive care unit.
In cases in which the occurrence of diabetic ketoacidosis signals a new diagnosis of diabetes, the process of education and support by the diabetes team should begin when the patient recovers.
In cases in which diabetic ketoacidosis occurs in a child with established diabetes, explore the cause of the episode and take steps to prevent a recurrence.
Following recovery from diabetic ketoacidosis, patients require subcutaneous insulin therapy.
Outpatient care
Organize outpatient care through the pediatric diabetes care team.
Consultations
Consult a neurosurgeon if cerebral edema is suspected.
Diet
Once the child has recovered, he or she can resume a normal diet.
Guidelines
The International Society for Pediatric and Adolescent Diabetes published guidelines for the management of diabetic ketoacidosis in children at http://www.ispad.org/FileCenter/10-Wolfsdorf_Ped_Diab_2007,8.28-43.pdf.
Fluid Replacement
Until relatively recently no randomized trials of fluid replacement had been conducted and, over the years, various regimens have been proposed. Published series suggest that the best outcomes have been achieved by using isotonic sodium chloride solution or half-strength sodium chloride solution for first resuscitation and replacement. [3] Slowly correcting the fluid deficit over 48 hours appears to be safer than rapid rehydration and, thus, forms the basis of the following regimen:
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Calculate fluid deficit by weight loss or clinical assessment to a maximum 8% of body weight
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In a child with severe acidosis or compromised circulation, an initial resuscitation of 10-20 mL/kg of isotonic sodium chloride solution (0.9%) can be administered over 30 minutes
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Remember to subtract any initial resuscitation fluid boluses given from the total calculated deficit
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After resuscitation, slowly correct the fluid deficit over 48 hours by providing normal maintenance fluids together with the calculated deficit
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Administer isotonic sodium chloride solution until blood glucose levels have fallen to 250-300 mg/dL (ie, 12-15 mmol/L), at which time glucose-containing fluids should be introduced (either 5% glucose with 0.9% saline or 5% glucose with 0.45% saline); continue maintenance with dextrose saline until the child is eating and drinking normally.
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If cerebral edema develops, restrict fluid replacement to two thirds of normal maintenance and replace the deficit over a period of 48 hours or longer
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Although strict assessment of fluid balance is important, replacement of ongoing losses is not normally required
The fluid maintenance rates typically advised for children are probably too generous for use in children with diabetic ketoacidosis. Table 2, below, can be used to calculate more appropriate infusion rates.
Table 2. Suggested Daily Maintenance Fluid Replacement Rates (Open Table in a new window)
Weight |
Infusion rate |
0-12.9 kg |
80 mL/kg/24 h |
13-19.9 kg |
65 mL/kg/24 h |
20-34.9 kg |
55 mL/kg/24 h |
35-59.9 kg |
45 mL/kg/24 h |
Adult (>60 kg) |
35 mL/kg/24 h |
Insulin Replacement
Continuous, low-dose, intravenous (IV) insulin infusion is generally accepted as the safest and most effective method of insulin delivery for treating diabetic ketoacidosis. Low-dose IV insulin infusion is simple, provides more physiologic serum levels of insulin, allows gradual correction of hyperglycemia, and reduces the likelihood of sudden hypoglycemia and hypokalemia.
The results of a prospective national study of diabetic ketoacidosis in the United Kingdom suggested a greater risk of cerebral edema in patients who received insulin within the first hour of treatment. [23] In light of these results, starting insulin therapy an hour after fluid resuscitation has commenced is prudent, especially in the newly diagnosed child.
The correct dose of insulin to infuse in the treatment of diabetic ketoacidosis is under debate. Traditionally, 0.1 U/kg/h is given, but a lower dose of 0.05 U/kg/h is enough to prevent gluconeogenesis and results in a slower reduction of blood glucose levels. One study showed no disadvantage to using the lower infusion rate of 0.05 U/kg/h. [45] Adolescents with secondary diabetic ketoacidosis and insulin resistance may need more than 0.1 U/kg/h.
Authorities commonly recommend that blood glucose levels not fall faster than 90 mg% (ie, 5 mmol/L) per hour. The infusion rate of insulin can be reduced as blood glucose levels fall but should not drop below 0.05 U/kg/h, to prevent any recurrence of ketosis. Do not discontinue infusion until subcutaneous insulin has been given when the child has recovered. If blood glucose falls below 120 mg% (ie, 7 mmol/L), increase the concentration of infused glucose to prevent hypoglycemia. Ketosis clears more quickly if insulin infusions are prolonged for 36 hours or more.
In cases of mild to moderate diabetic ketoacidosis in which the patient is able to tolerate oral fluids, giving repeated (hourly) subcutaneous injections of regular or fast-acting analogue insulins in a dose of 0.1 U/kg is possible. This is as effective as IV insulin. [46, 47]
Electrolyte Replacement
Potassium
Patients with diabetic ketoacidosis always have a total-body deficit of potassium. After initial resuscitation and if serum/plasma levels are below 5 mEq/L or a good renal output has been maintained, add potassium to all replacement fluids.
Table 3, below, provides examples of infusion concentrations in milliequivalents per liter for differing degrees of potassium status. Potassium chloride most commonly is administered. This theoretically could make the acidosis worse, but no evidence indicates that administration of other potassium salts, such as phosphate or acetate, is more effective.
Table 3. Infusion Rates of Potassium Chloride (Open Table in a new window)
Serum/Plasma K+ (mEq/L) |
Potassium Chloride (KCL) Dose in Infusion Fluids |
< 2.5 mEq/L |
Carefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h |
2.5-3.5 mEq/L |
40 mEq/L |
3.5-5 mEq/L |
20 mEq/L |
5-6 mEq/L |
10 mEq/L (optional) |
Over 6 mEq/L |
Stop K+ and repeat level in 2 h |
Bicarbonate
Although metabolic acidosis may be severe, no evidence supports the administration of IV sodium bicarbonate to improve outcomes; on the contrary, the evidence indicates that IV bicarbonate may cause harm and delay recovery. [48, 49] Failure of the acidosis to improve with treatment more likely reflects inadequate fluid and insulin replacement. The only justification for using IV bicarbonate is acidosis sufficiently severe to compromise cardiac contractility.
Other electrolytes
Although patients usually have an absolute deficit of phosphate and magnesium, no evidence indicates that either needs to be replaced in patients with diabetic ketoacidosis.
Treatment of Cerebral Edema
If cerebral edema is suspected and hypoglycemia is excluded, prompt treatment with an osmotic diuretic is indicated, followed by a CT scan and referral to a neurosurgeon. Intubation, hyperventilation, and intracranial pressure monitoring reportedly improve outcomes.
Although mannitol has been the most commonly used osmotic diuretic, theoretical and experimental reasons for using hypertonic saline (3%) have been noted. [50] The usual dose of mannitol to treat cerebral edema is 0.5-1 g/kg infused over 30 minutes, which can be repeated after 1 hour. The usual dose of hypertonic saline is 5-10 mL/kg, again infused over 30 minutes, which can be repeated after 1 hour.
Only half of children who develop cerebral edema have obvious signs of deterioration; children may present with respiratory arrest. Young children have a greater risk of respiratory arrest, and the outcome for these children is particularly bad. A United Kingdom study reported that every child who presented with respiratory arrest either died or was left with neurologic deficits.
Monitoring
Attention to detail is important to achieving a good outcome. Carefully monitor potassium status to prevent complications from hypokalemia.
Hypoglycemia should not occur with adequate monitoring and is less likely if low-dose, continuous insulin infusions are administered together with dextrose when blood glucose levels fall below 200 mg/dL (11 mmol/L).
Specifically designed recording charts (see the images below) make the process of care much easier. Ideally, these charts include all important measurements of clinical and biochemical status, fluid balance, and insulin prescription.
Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 1 of 4).
Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 2 of 4).
Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 3 of 4).
Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 4 of 4).
Frequent review of neurologic status—at least hourly (or any time a change in the level of consciousness is suspected)—is essential during the first 12 hours of diabetic ketoacidosis treatment. Promptly treat any suspected cerebral edema.
Deterrence and Prevention
Diabetic ketoacidosis in a patient in whom diabetes is newly diagnosed can be prevented only if the general public and primary care physicians know the symptoms and if physicians are alert, particularly with regard to young children, to the possibility of diabetic ketoacidosis developing. [51] A urine test for glycosuria is easy to perform.
Adequate education and support for patients with established diabetes (and for their families) should prevent diabetic ketoacidosis occurring as a result of illness (see the videos below). Intervention is much more difficult when insulin is withheld deliberately or administered improperly. Identification of children at risk for such behaviors and intervention with social and psychological support may alleviate these problems. [52]
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Pediatric Diabetic Ketoacidosis. Glasgow Coma Scale, modified for age of verbal response.
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Pediatric Diabetic Ketoacidosis. A graphical representation of the electrocardiographic changes of hypokalemia.
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Pediatric Diabetic Ketoacidosis. A graphical representation of the electrocardiographic changes of hyperkalemia (due to overcorrection of potassium loss).
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Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 1 of 4).
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Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 2 of 4).
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Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 3 of 4).
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Pediatric Diabetic Ketoacidosis. Diabetic ketoacidosis treatment and results chart (page 4 of 4).
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Pediatric Diabetic Ketoacidosis. Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
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Pediatric Diabetic Ketoacidosis. Diabetes Sick Day Rules.
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Pediatric Diabetic Ketoacidosis. Taking Diabetes Back to School.
Tables
|
Mild (< 3%) |
Moderate (3-8%) |
Severe (8%) and Shock (>10%) |
Appearance |
Thirsty, alert |
Thirsty, lethargic |
Drowsy, cold |
Tissue turgor |
Normal |
Absent |
Absent |
Mucous membranes |
Moist |
Dry |
Very dry |
Blood pressure |
Normal |
Normal or low |
Low for age |
Pulse |
Normal |
Rapid |
Rapid and weak |
Eyes |
Normal |
Sunken |
Grossly sunken |
Anterior fontanelle |
Normal |
Sunken |
Grossly sunken |
Weight |
Infusion rate |
0-12.9 kg |
80 mL/kg/24 h |
13-19.9 kg |
65 mL/kg/24 h |
20-34.9 kg |
55 mL/kg/24 h |
35-59.9 kg |
45 mL/kg/24 h |
Adult (>60 kg) |
35 mL/kg/24 h |
Serum/Plasma K+ (mEq/L) |
Potassium Chloride (KCL) Dose in Infusion Fluids |
< 2.5 mEq/L |
Carefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h |
2.5-3.5 mEq/L |
40 mEq/L |
3.5-5 mEq/L |
20 mEq/L |
5-6 mEq/L |
10 mEq/L (optional) |
Over 6 mEq/L |
Stop K+ and repeat level in 2 h |
