Diabetic Ketoacidosis
Diabetic Ketoacidosis
General and supportive measures
ICD-10 Code: E10.1
DESCRIPTION
Diabetic ketoacidosis (DKA) occurs with relative or absolute insulin deficiency, either caused by non-adherence to insulin regimens or by excessive secretion of counter-regulatory hormones during stress, e.g. infection, trauma and surgery.
DIAGNOSTIC CRITERIA
- Heavy glycosuria (3+ or more).
- Hyperglycaemia, i.e. blood glucose usually > 11 mmol/L, ketonuria 2+.
- Blood gas: pH < 7.3, bicarbonate < 15 mmol/L.
- Polyuria, polydipsia and dehydration.
- Kussmaul respiration, nausea, vomiting, abdominal pain and depressed level of consciousness are all late signs.
Note: In rare cases, blood glucose is not elevated.
Children with mild dehydration and not clinically unwell usually tolerate oral rehydration and subcutaneous insulin.
See: Guidelines for management of diabetics on sick days.
GENERAL AND SUPPORTIVE MEASURES
- Admit all children and adolescents to an ICU or ward experienced in the management of DKA in children and adolescents, if possible.
- Ensure patent airway.
- If the child is comatosed, secure the airway and insert a urinary catheter.
- If comatosed or has recurrent vomiting insert an oro-/nasogastric tube and apply free drainage.
MEDICINE TREATMENT
Seek specialist advice early in the management.
If hypoxaemic:
- Oxygen via facemask.
The objectives of fluid and sodium replacement therapy in diabetic ketoacidosis are:
- To restore circulating volume.
- To replace sodium and water deficits from extracellular and intracellular compartments.
- To restore glomerular filtration rate to enhance clearance of glucose and ketones from the blood.
- To reduce the risk of cerebral oedema.
Fluids
a: Fluids for resuscitation in shock:
- Sodium chloride 0.9%, IV, 10–20 mL/kg over 10–30 minutes.
- Repeat if shock persists.
b: Fluid requirements after resuscitation
Maintenance (over 24 hrs)
| ≤ 10 kg | 100 ml/kg/24 hrs |
| 11–20 kg |
1000 ml + 50 ml/kg/24 hrs for each kg from 11– 20 kg |
| > 20 kg | 1500 ml + 20 ml/kg/24 hrs for each kg > 20 kg |
Obese children: Use ideal body weight for height.
+
Rehydration (over 48 hours)
| 5% dehydrated | 50 ml/kg/48 hrs |
| 10% dehydrated | 100 ml/kg/48 hrs |
Review at least 2 hourly.
+/-
Ongoing losses
| Replace urine loss in excess of 2 ml/kg/hour |
= urine output (in ml/kg/hr) - 2 ml/kg/hr |
Review at least 2 hourly.
Examples of fluid volumes for subsequent phase of rehydration (i.e. maintenance + 5% of body weight/24 hours)
|
Body weight (kg) |
Maintenance (mL/24 hour) |
Maintenance + 5% of body weight (mL/24 hrs) |
Maintenance + 5% of body weight (mL/hour) |
|
4 |
325 |
530 |
22 |
|
5 |
405 |
650 |
27 |
|
6 |
485 |
790 |
33 |
|
7 |
570 |
920 |
38 |
|
8 |
640 |
1040 |
43 |
|
9 |
710 |
1160 |
48 |
|
10 |
780 |
1280 |
53 |
|
11 |
840 |
1390 |
58 |
|
12 |
890 |
1490 |
62 |
|
13 |
940 |
1590 |
66 |
|
14 |
990 |
1690 |
70 |
|
15 |
1030 |
1780 |
74 |
|
16 |
1070 |
1870 |
78 |
|
17 |
1120 |
1970 |
82 |
|
18 |
1150 |
2050 |
85 |
|
19 |
1190 |
2140 |
89 |
|
20 |
1230 |
2230 |
93 |
|
22 |
1300 |
2400 |
100 |
|
24 |
1360 |
2560 |
107 |
|
26 |
1430 |
2730 |
114 |
|
28 |
1490 |
2890 |
120 |
|
30 |
1560 |
3060 |
128 |
|
32 |
1620 |
3220 |
134 |
|
34 |
1680 |
3360 |
140 |
|
36 |
1730 |
3460 |
144 |
|
38 |
1790 |
3580 |
149 |
|
40 |
1850 |
3700 |
154 |
|
45 |
1980 |
3960 |
165 |
|
50 |
2100 |
4200 |
175 |
|
55 |
2210 |
4420 |
184 |
|
60 |
2320 |
4640 |
193 |
|
65 |
2410 |
4820 |
201 |
|
70 |
2500 |
5000 |
208 |
|
75 |
2590 |
5180 |
216 |
|
80 |
2690 |
5380 |
224 |
Note: Sodium chloride 0.9% is preferred for resuscitation and the initial phase of rehydration. However, to prevent the occurrence of hyperchloraemic acidosis switch to sodium chloride 0.45%/dextrose 5% after blood glucose has fallen to 12 mmol/L or less. Monitor sodium and chloride (on VBG) 4–6 hourly and adjust maintenance fluids as necessary.
Note: One of the danger signals for cerebral oedema is a precipitous drop in the serum sodium level.
Bicarbonate
Bicarbonate use is associated with increased risk of cerebral oedema. It should not be used routinely to improve adicosis.
Caution:
Consult a specialist before administering any bicarbonate solution.
Potassium
Commence potassium replacement immediately unless patient has anuria. If serum potassium is high, start replacement after the patient has passed urine.
Early addition of potassium in the fluid regimen (KCl 15% 20mL in 1L = 40 mmol/L) is essential even if the serum concentration is normal as insulin will drive glucose and potassium into the cells.
DKA protocol:
Two-bag system – Alternative fluid and electrolyte treatment
Under supervision of a specialist.
The two-bag system consists of 2 bags of identical electrolyte content but different dextrose concentrations, 0% and 10%, administered simultaneously into a single IV line. Variations in dextrose delivery are achieved through changing the proportions of the 2 bags contributing to the total rate, which is determined by the degree of dehydration.
- Sodium chloride 0.9%, IV, 10–20 mL/kg.
- May be repeated if necessary.
- Then switch to the two-bag system.
| Bag 1 (dextrose 0%) |
Bag 2 (dextrose 10%) |
| Sodium chloride 0.45%, 1 L PLUS Potassium chloride, 20 mL |
Dextrose 10%, 1 L PLUS Sodium chloride 5%, 90 mL PLUS Potassium chloride, 20 mL |
Run these two riders for easy titration of dextrose from dextrose 10% to dextrose 0%:
| Fluid | Blood glucose > 15 mmol/L |
Blood glucose 10–15 mmol/L |
Blood glucose < 10 mmol/L |
| Bag 1 | 100% | 50% | 0% |
| Bag 2 | 0% | 50% | 100% |
Insulin
- Insulin, short acting, 0.05-0.1 units/kg/hour as a continuous IV infusion.
- Add insulin, 50 units (0.5 mL) to 50 mL sodium chloride 0.9% in a syringe pump to get a solution of 1 unit/mL.
- Use a separate cannula and line for insulin administration.
- Do not add insulin directly to the fluid bags administering maintenance and rehydration fluids.
If the rate of blood glucose fall exceeds 5 mmol/ L/hour or the blood glucose falls to 17 mmol/L: - Add a dextrose-containing fluid.
- Do not stop the insulin infusion while dextrose is being infused.
If the blood glucose falls below 5 mmol/L: - Give a bolus of 2 mL/kg of dextrose 10% and increase the concentration of dextrose in the infusion.
Continue with IV insulin until: - base deficit is < 5 or bicarbonate is ≥ 15 mmol/L,
- there is no ketonuria, and
- blood glucose is ≤ 10 mmol/L.
Alternative to insulin infusion
Where there are no facilities for insulin infusion, e.g. no syringe pumps, staff constraints, etc.:
- Insulin short-acting, IV, 0.1 unit/kg, hourly.
Changing from intravenous to subcutaneous insulin
Continue with intravenous fluids until the child is drinking well and able to tolerate snacks. When oral fluids are tolerated, reduce intravenous fluids. Subcutaneous insulin can be started once the child is well hydrated and able to tolerate a normal diet.
The most convenient time to change to subcutaneous insulin is just before a meal. Administer the first dose of subcutaneous insulin 30 minutes before the meal and continue with the insulin infusion for 90 minutes after the subcutaneous injection to prevent rebound hyperglycaemia.
In newly diagnosed diabetics, basal-bolus regimen is started as described in Type 1 Diabetes Mellitus – Insulin Regimens, in a low range dose:
- Prepubertal children: 0.7 units/kg.
- Pubertal children: 1 unit/kg.
In established diabetics, give maintenance insulin.
Give supplemental subcutaneous short-acting insulin before meals if the blood glucose > 11 mmol/L:
| Blood glucose (mmol/L) |
Short-acting insulin (units/kg/dose) |
| 11-12 | 0.06 |
| 13-16 | 0.09 |
| 16 | 0.12 |
REFERRAL
- No improvement.
- Deterioration of condition, i.e.:
- pH <7.1,
- hyperventilation,
- shock,
- depressed level of consciousness,
- persistent vomiting,
- age < 5 years.
- Rising blood glucose.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 7: Endocrine, 7.5 Diabetes Mellitus, 7.5.2 Diabetes Mellitus, Insulin Dependent: Acute Complications, 7.5.2.2 Diabetic Ketoacidosis