1. Diagnosis of diabetic ketoacidosis (DKA)
Dr. Abdullah Alshaya
Consultant Pediatric Endocrinologist

2. DKA Hyperglycemia: Blood glucose level greater than 200 mg/ dL.
2. Ketonemia: Ketones demonstrable in serum
3. Acidosis: pH less than 7.35 and HCO3 less than 15 mEq/ L.
4. Glucosuria and Ketonuria
5. The clinical manifestations of diabetes

3. Diagnosis and Assessment
Think of DKA in a known diabetic child or any child who presents with either of or a combination of the following
Classical symptoms of diabetes
Acute abdomen
Dehydration
Acidotic breathing
Disturbed level of consciousness

4. Important Relevant Points
1st. History
Precipitating factors including insulin omission accuracy of dose, stressful conditions including infections, trauma or home conflict.
History of recent weight and weight loss.

5. 2nd. Examinations
Signs and complications of fluid, electrolyte and acid base imbalance including shock, hypotension with acidosis, and CNS status. Establish degree of dehydration (mild, moderate and severe).
Look for signs of hidden infection and trauma.
Obtain accurate weight before starting treatment if possible.

8. Classification of diabetic ketoacidosis (DKA)
Normal
Mild
Moderate
Severe
CO2 (mEq per L, venous)*
20-28
16-20
10-15
<10
pH (venous)*
<7.15
Clinical
No change
Oriented, alert but fatigued
Kussmaul respirations; oriented but sleepy; arousable
Kussmaul or depressed respirations; sleepy to depressed sensorium to coma

9. Classification of diabetic ketoacidosis (DKA)
Co2 and pH measurement are method dependent; normal ranges may vary. Severe hypernatremia (corrected Na>150 mEq/L) would also be classified as severe DKA (2011)

10. Management of Ketoacidosis
The immediate aim of therapy are expansion of the intravascular volume, correction of deficits in fluid electrolytes and acid-base status and initiation of insulin therapy.

11. Principles of Management
Treatment of shock
Correction of dehydration and replacement of losses with provision of maintenance
Correction of electrolyte deficit
Correction of hyperglycemia
Correction of acidosis
Treatment of precipitating factors including sepsis
Observation for and treatment of cerebral oedema
Prevention of further attacks

12. Fluid and Electrolyte Therapy
It is designed to restore most electrolyte deficits, to reverse the acidosis, and to rehydrate the moderately ill child in about 24 hr. A standard water deficit (85 mL/kg) is assumed. This amount, when added to maintenance, yields about 4 L/m² for children of all sizes.
The maximum volume: it is prudent to anticipate clinical cerebral edema in all children treated for DKA by limiting the rate of fluid administration to 4.0 L/m²/24hr or less.

13. LAB Blood for: glucose urea, creatinine electrolytes gases osmolality,
CBC + diff, (culture: if indicated)
9. Urine: urinalysis + culture (for glucose + ketone)

14. Fluid and Electrolyte Therapy
This protocol corrects a deficit of 85 mL/kg (8.5% dehydration) for all patients in the first 24 hr. Children with milder DKA recover in hr (and need less total IV fluid before switching to oral intake), whereas those with more severe DKA require hr with this protocol.

15. Diabetic Ketoacidosis (DKA) Treatment Protocol
Time
Therapy
Comments
1st hour
10-20 mL/ kg IV bolus 0.9% NaCI or lactated ringer
Insulin drip at U/kg/hr
Quick volume expansion; may be repeated. NPO. Monitor I/O, neurologic status. Use flow sheet. Have mannitol at beside; 1 g/kg IV push for cerebral edema.
2nd hour until DKA resolution
0.45% NaCI; plus continue Insulin drip 20 mEq/ L potassium phospate and 20 mEq/L potassium acetate 5% glucose if blood sugar <250mg/ dL
85mL/kg + maintenance- bolus
IV rate= hr
If K<3 mEq/L, give 0.5 to 1.0 mEq/ kg as oral K solution OR increase IV K to 80 mEq/L
Variable
Oral intake with subcutaneous insulin
No emesis, CO2 ≥16 mEq/ L; normal electrolytes

16. Admission, hr 8, 16,24, then daily
Parameter
Recommended
Recommended items
1. Clinical features
Neulogic check
Vital signs
weight
Every min
Admission, hr 8, 16,24, then daily
b. Na, K, CI, osmolarity
c. Glucose
d. BUN
e. Urinary ketones
f. ECG
2. Fluid Balance
Intake (PO, IV)
Output (urine and stool)
3. Chemical analysis
Arterial blood gases
(ABGs) (pH, HCO3)
Admission, hr 2, 6, 10, 24
g. Serum Ca
4. Blood culture
5. Urinalysis
(bacteria, WBCs)
Admission hr 2,6,10,24
Hourly for 24 hrs.
Admission, hr 6, 24
Admission hr 6, 10, 24
Admission hr 2, 6 OR
Continous if K is <3.5 mEq/L or >7 mEq/L
When phosphate is used Admission
Admission

17. Fluids
If patient is shocked give 10 ml/kg of normal saline as quickly as possible ( minutes). Repeat these doses till circulation is restored in the emergency room
If not shocked or once circulation is restored, start IV fluids as mentioned below.

18. Fluid Replacement
Fluid repair should extend over 48 hours to achieve a slower correction of serum hyperosmolality to prevent cerebral oedema. Therefore deficit should be given over 48 hours
Maintenance needed for 24 hours

19. Deficit The usual deficit in most DKA patients ranges from 5-10% however this should be assessed clinically
Age
< 2 years
Mild 5%
Moderate
5-10%
Severe
10-15%
> 2 years 3% 6% 9%

20. Rate of Infusion
Add 24 hours maintenance + ½ calculated deficit and divide by 24 to obtain the hourly rate, (or add 48 hours maintenance plus calculated deficit and divide this total by 48 to get the hourly rate)

21. Fluid used Use normal saline when blood glucose reaches 13 mmol/L change to 5% dextrose with 0.45 normal saline (or normal saline in older children and adolescents)

22. Infusion rate: 0. 1 unit/kg/hour i. e
Infusion rate: 0.1 unit/kg/hour i.e. 0.1 ml/kg/hour of the above-mentioned preparation. Aiming to reduce blood glucose at rate of mmol/hr.
Continue this insulin infusion till acidosis is cleared i.e. either pH > 7.3, HCO3 > 15 mmol or normal anion gap (16-18)
Note: Discontinuation of insulin infusion is not dictated by blood sugar level, but by clearance of acidosis.

23. Sodium
Osmotic flux of water into extracellular space reduces serum sodium concentration
Actual sodium: 1.6mEq/L per 100mg/dL rise in glucose over 100
Hypertriglyceridemia  low sodium  pseudohyponatremia

24. Potassium
Level varies depending on urinary loss and severity of acidosis
Potassium moves extracellularly in exchange for hydrogen ions  typical hyperkalemia on presentaion
Total body stores are depleted due to urinary loss

25. Potassium
Commenced when the child starts to pass urine or if he is already passing urine and or K is below 5 mmol/L)
Add 40 mmol/L of potassium chloride
Monitor by EKG, clinically & biochemically
If serum potassium is > 6 mmol/L withhold potassium temporarily.

28. Management Bicarbonate is almost never administered
Bicarb administration leads to increased cerebral acidosis:
HCO3- + H+  dissociated to CO2 and H2O
Bicarbonate passes the BBB slowly
CO2 diffuses freely  exacerbating cerebral acidosis & depression
Indications for bicarbonate use: only in severe acidosis leading to cardiorespiratory compromise

29. Bicarbonate
Dose: Wt Kg X 0.3 X 22 - HCO3 level (or base deficit) divided by 2
Infuse over 4-6 hours

30. Phosphorous
We don’t use it as a routine. Consider using it in comatose patients or if phosphate level < 0.5 mmol/L. Give the dose as potassium phosphate and half as potassium chloride. Monitor calcium levels every 4-6 hours as patient might develop hypocalcemia. Always check serum calcium level before phosphate is infused.

31. Monitoring
Blood glucose with a meter hourly during insulin infusion (at least hourly for 1st 4-6 hours then 2 hourly if needed) then every 6 hours thereafter.
Blood gases, blood glucose, urea and electrolytes and blood for ketone using optium meter 4-6 hourly

32. Vital signs (EKG monitor) and neuro observation (initially hourly till stable then 4-6 hours). Also watch for headache, vomiting or behavior change.
Flow sheet to record: blood work up, intake and output, doses of insulin, and urinalysis for glucose ketone. Adequate urine output =>1.5 ml/Kg/hr.

33. Problem Solving During Monitoring
After resuscitation, the typical aim of rate of blood glucose fall is mmol/hour
When blood glucose falls to < 15 mmol/L change fluids to 5% dextrose with 0.45 saline (or normal saline in older children and adolescents) to maintain blood glucose in the desired range of mmol/L
If blood glucose rises again above 15 mmol/L increase the insulin infusion by 25%

34. If blood glucose falls below 8 mmol/L or falls too rapidly increase the concentration of glucose to 10% (or more)
The insulin infusion rate should only be decreased if blood glucose levels remains below the target range despite glucose supplementation
Don’t stop insulin infusion or decrease below 0.05 unit/kg/hr particularly if the patient is still acidotic

35. Management of Ketoacidosis
Neurologic check: Sensorium, change of consciousness, headache, bradycardia, apnea, pupillary changes, papilledema, posturing, and seizures

36. Problems and Complications
Cerebral Oedema
Warning signs and symptoms
Headache and slowing of heart rate (not necessarily bradycardia)
Vomiting
Change in neurological status (restlessness, irritability increased drowsiness, incontinence) or specific neurological signs (e.g. cranial nerve palsies)

37. risk factors Younger age New onset Longer duration of symptoms
Lower PCO2
Severe acidosis
Increase in BUN
Use of bicarbonate
Large volumes of rehydration fluids
Failure of correction of Na with treatment
Bicarb has been linked to increasing the risk of cerebral edema: case controlled study it was found early administration of insulin and high volumes of fluid were important predictors of cerebral edema, not bicarb therapy

38. Rising blood pressure, decreased O2 saturation
Rising blood pressure, decreased O2 saturation. More dramatic changes such as convulsions, papilloedema and respiratory arrest are late . signs and are associated with extremely poor prognosis action.
Exclude hypoglycemia
Give immediate mannitol 1 gm/kg over 20 minutes (i.e. 5 ml kg of 20% solution) (3% saline can be used if no mannitol available.

39. Have rehydration infusion rate until situation is improved
Nurse child head elevated
Move to PICU (or even earlier if possible)
Call you senior
assisted ventilation may required

40. Consider continuation of mannitol at 0
Consider continuation of mannitol at 0.25 gm/kg/hr to prevent rebound increase in ICP or repeat bolus every 4-6 hours
Cranial imaging should only be considered after child is stabilized as other intracranial events as thrombosis, hemorrhage and infarcts may occur. Note: a normal CT doesn’t exclude cerebral oedema. It is a clinical diagnosis.

41. Definition
Phase 1
Phase II
Phase III
Phase IV
Phase V
Emergency Room
Till acidosis is cleared (normal anion gap) PH > 7.3 or HC03 > 18 or blood ketone <1.5 pmol/L
From clearing of acidosis to: pt. starting to drink and eat
When patient is able to drink and eat (24-72 hours)
Long-term
Investigation
Dextrostix
B.G.
U. E.
A. B. G.
Urinalysis Culture if indicated CBC
Infection Screen
B glucose 1-2 hourly Blood & or urine ketones U. E. 4-6 hourly Blood Gases
Urine for glucose + ketone 6 hourly
Blood Glucose 6 hourly before meals U/E hourly Urine
Blood Glucose (meter) 6 hourly U/E once/day Urine 6 hourly
Blood Glucose x 4
Urine x 4
Fluids
Electrolytes
Normal Saline ml/kg if shocked
Repeat till shock is over Start IV fluids
Normal Saline
Change to 5% D + '/2 NS if B- sugar 13 mmol/L (250 mg.dl) K+, P04 + HCO3 (if indicated)
5% D + Zi NS (or normal saline) Oral fluids + food
K+ gradually stop I.V.
Reduce I.V. fluids Gradually and stop
Stop I.V.
Insulin
I.V. Regular insulin 0.1 unit/kg per hour
0.1 U/kg/hour I.V.
f dose to 0.15 — 0.2 units/kg if no improvement in 2-4 hours
Low dose infusion (0.05 u/kg or S/C regular or usual dose)
May start NPH S/C + Regular
S/C
Stop I.V. 1-2 days S/C
Diet + Oral
NPO
Try oral fluids after 4 hours After vomiting stops
Try oral fluids/food
Food
Diabetic diet
Others
History Examination Coma care Stomach suction Reassure
Charts ->
ECG RI Infection PICU Vital signs Neuro Observation Parents
Education

42. Thank you!!!