Diabetic ketoacidosis, or DKA, is severe, out-of-control diabetes (high blood sugar) that needs emergency treatment. DKA is caused by a profound lack of circulating insulin. This may happen because of illness, taking too little insulin, or getting too little exercise. The body starts using stored fat for energy, and ketone bodies (acids) build up in the blood. DKA also accounts for most hospitalization and is the most common cause of death, mostly due to cerebral edema, in pediatric diabetes. Furthermore, treating DKA incorrectly can result in cerebral edema and death.
The Barbara Davis Center for Childhood Diabetes in Denver, Colorado, has prepared an excellent poster for hospital emergency rooms with the correct treatment procedures for DKA and suspected cerebral edema. The guidelines are as follows:
- Venous (or arterial) pH < 7.10
- HCO3 <8 mEq/L
- Usually large urine ketones on dipstick
- Breath may have “fruity” odor
- Often Kassmaul respirations
- Treat at facility with pediatric ICU
Treatment of DKA:
- Rehydration: 20 ml/kg bolus in first 1-2 hours (NS or LR)
- NPO if vomiting
- Insulin drop: 0.1 U/kg per hour IV
- If still dehydrated after 1-2 hours: can repeat bolus of 20 ml/kg NS or LR over 1-2 hours–MAXIMUM BOLUS MUST BE <40 ml/kg;; then fluilds (0.45NS) at 1.5 times maintenance. Give no more than 4L of fluid/m2/24 hours (including initial bolus)
- Add potassium (K+) when pH > 7.1 and serum K+ known to be normal or low (may use 20 mEq/L KPO4 and 20 mEq/L KAc [or KCl])
- Aim for glucose fall of 100 mg/dl per hour
- Add 5% dextrose to IV when blood glucose falls to 200-250 mg/dl
- Repeat electrolytes and venous pH hourly until pH > 7.1; then repeat every 2 hours until > 7.2 and then every 4 hours until > 7.3
Cerebral Edema: A Clinical Emergency!
- Suspect if bad headache, excessive lethargy, or any deterioration in mental status
- Dilated or non-responsive pupils are often the first sign
1. Mannitol, 1 gm/kg IV over 30 minutes — if patient improves and later worsens it may need to be repeated (give immeditately upon suspected cerebral edema)
2. Reduce fluids (<70cc/kg per day)
3. Elevate head of bed
4. Hyperventilation until pCO2=25 to 27 mm Hg
- Type 1 Diabetes Treatment poster by H. Peter Chase, M.D., University of Colorado Health Sciences Center, 1999.
- Diabetic Ketoacidosis (DKA): Treatment Guidelines by Arlan L Rosenbloom, M.D. and Ragnar Hanas, M.D.