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Diabetic ketoacidosis
Algorithm for the immediate assessment and management of diabetic ketoacidosis (DKA) in children
(Figure 5.6)
Hypoglycaemia
Diabetic ketoacidosis
Diabetic ketoacidosis is a medical emergency requiring urgent hospital admission.
Diabetic ketoacidosis (DKA) is a medical emergency that requires hospital admission and intravenous fluid,
electrolyte, and insulin therapy. There are many different approaches to managing DKA in children. This section
provides one approachdifferent institutions may have varying local protocols.
An algorithm summarising the immediate assessment and management of DKA is shown in Figure 5.6.
In a child with DKA, fluid replacement should start immediately, before insulin therapy. Rapid rehydration increases
the risk of precipitating acute cerebral oedema, which has a high mortality rate. Urgent consultation with an expert in
paediatric diabetes is essential. Volume expansion (resuscitation) is required only if needed to restore peripheral
circulation.
Fluid and electrolyte replacement has to take into account:
addition of glucose when the blood glucose concentration approaches 14 to 17 mmol/L, or sooner if the fall
in blood glucose concentration is precipitous.
There is always a total body deficit of potassium, even if serum potassium concentrations are normal or high at
presentation. Bicarbonate therapy is required only in extreme circumstances and may increase the risk of cerebral
oedema.
Short-acting insulin should be given by intravenous infusion, titrated against the response of hourly finger-prick blood
glucose concentrations. Use:
Cerebral oedema is an uncommon (less than 1%) but serious life-threatening complication of managing DKA in
children. Risk factors include:
younger age
Early signs that cerebral oedema is developing are a falling serum osmolality, headache, and irritability or an altered
conscious state. While serum osmolality is the main risk factor, in practice often the corrected sodium concentration
[Note 1] is used as a surrogate marker of serum osmolality. Therefore the goal is to keep the corrected sodium
concentration stable during treatment.
Late signs of cerebral oedema are bradycardia, increased blood pressure and depressed respiration.
Patients should be nursed in an intensive care setting with neurological assessment that includes neuroradiological
imaging. Intubation and ventilation may be required.
Treat cerebral oedema when suspecteddo not delay treatment while waiting for confirmatory neuroimaging if
cerebral oedema is diagnosed on clinical grounds. Treatment involves lowering the rate of fluids being administered,
along with:
Hypoglycaemia
Hypoglycaemia is of particular concern in children with diabetes who are younger than 5 years. This is because of its
potential to cause seizures, and children's greater susceptibility to brain injury, including seizure disorder and
intellectual damage. This is especially so when the child is unable to adequately recognise and communicate the
symptoms of hypoglycaemia to carers. Young people with diabetes should always have immediate access to glucose
tablets or sweets.
When treating hypoglycaemia, if the child is conscious and cooperative, use:
1 tablespoon of honey
glucose 10% 2 mL/kg IV as a bolus over a few minutes, until blood glucose
concentration normalises (more than 4 mmol/L)
FOLLOWED BY
sodium chloride 0.45% with glucose 5% IV (maintenance fluids), at
Note 1: Corrected sodium concentration = measured sodium concentration + (0.3 [blood glucose concentration
5.5]) (all concentration units in mmol/L)
Related topics:
Management of type 1 diabetes in children
Chronic complications
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