Diabetic Ketoacidosis (DKA) In Children

DKA is considered as one of the paediatric emergencies. 

This occurs as a complication of diabetes mellitus and in children, it usually occurs following type 1 DM. 

Pathogenesis

Deficiency of insulin
        ↓
Hyperglycemia, resulting from

  • Increased gluconeogenesis from fat and proteins
  • Glycogenolysis

        ↓
Hypersecretion of stress hormones (Glucagon, cortisol, catecholamines, growth hormone)
        ↓
Liplysis produces excess fatty acids 
        ↓
Ketogenesis


Causes Of DKA

  1. First presentation of undiagnosed diabetes (In 25% of cases)
  2. Failure of administration of insulin
  3. Emotion (Stress)
  4. Following infection
 
 
Clinical Presentation Of DKA
  1. Symptoms of hyperglycemia (Polyuria, Polydipsia, Nocturia, Weight loss)
  2. Abdominal pain and vomiting (Due to mesenteric ischemia)
  3. Acidotic breathing / Kussmaul breathing
  4. Confusion / Coma
 
 
Diagnosis of DKA
  • RBS > 200mg/dL
  • Urine ketone bodies – Positive
  • ABG – pH < 7.35
 
 
Management Of DKA
  1. Consider this as an emergency and attend urgently
  2. Admit the patient to the HDU with monitoring facilities 
  3. Commence resuscitation (A, B, C) and meanwhile the resuscitation is going on check CBG
  4. High flow oxygen via face mask 
  5. Secure an IV channel
  6. Draw blood for investigations
    • ABG, urine for ketone bodies, RBS 
    • S. Cr, BU, SE (Potassium, Sodium)
    • FBC, blood culture, CRP
  7. If the patient is in shock – Start 10ml/kg bolus 
    • 20ml/kg boluses are not given to avoid development of cerebral oedema
  8. Assess the level of consciousness 
    • If GCS is low — Insert NG tube to prevent aspiration
  9. Determine the degree of dehydration 
    • Mild (3%) 
    • Moderate (5%) – Reduced skin turgor, dry mucous membranes
    • Severe (8%) – Sunken eyes, reduced urine output
  10. Calculate the deficit 
    • Deficit = Weight x Percentage of dehydration x 10 (Constant)
  11. Start IV fluids ; Total fluid is given over 48 hours
    • Total fluid = Maintenance + Deficit 
    • Maintenance is obtained by a chart according to their weight
  12. Monitoring of the patient
    • Vitals
    • UOP
    • CBS
    • SE
    • ABG
  13. After ensuring patient is not anuric, add 20mmol of Potassium to each bottle of normal saline
  14. From the 2nd hour — Start IV soluable insulin infusion at a rate of 0.1U/kg/hr 
  15. If there is evidence of infection – Start IV antibiotics 
  16. If pH < 7.1 – Start sodium bicarbonate after consulting with the seniors 
  17. When CBG drops to < 180mg/dL
    • Reduce insulin infusion rate gradually
    • Give IV normal saline + IV 5% dextrose alternatively
  18. Once child improves and urine is free of ketone bodies
    • Start S/C insulin and continue for life 
    • Remember not to stop insulin infusion suddenly  
 
Patient not responding to treatment, possible causes….
  1. Cerebral oedema
  2. Hypoglycemia
  3. Sepsis, left untreated
  4. Hypochloremic metabolic acidosis 
 
 
Complications Of DKA
  1. Cerebral oedema
  2. Hypoglycemia
  3. Hypokalaemia 
  4. Aspiration pneumonia
  5. Hypochloremic metabolic acidosis
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