Management of Diabetic Ketoacidosis in Children - Diabetic Ketoacidosis for Health Providers

Management of Diabetic Ketoacidosis in Children
Question
How is diabetic ketoacidosis managed in the pediatric age group?

Expert
Response from Jos» F. Cara, MD
Associate Professor, Department of Pediatrics, Wayne State University School of Medicine; Division Head, Department of Pediatrics, Endocrinology & Diabetes, Children's Hospital of Michigan, Detroit.

Despite significant advances in the management of childhood diabetes and in our understanding of the pathophysiology of the condition, diabetic ketoacidosis (DKA) remains a serious condition with significant morbidity and mortality.[1] Appropriate recognition and aggressive treatment by individuals experienced in the management of DKA are important for a successful outcome. Two excellent manuscripts describing the treatment guidelines for childhood DKA have recently been published.[1,2]

In general, diabetic ketoacidosis can be arbitrarily considered as mild, moderate, or severe based on the clinical and biochemical presentations. Mild DKA is typically associated with hyperglycemia and ketonuria with a preserved ability to take in and retain oral fluids. It can be corrected with increased fluid intake (diet drinks when blood glucose levels are >/= 240 mg/dL) and supplemental insulin lispro or regular insulin administration. Moderate DKA is characterized by hyperglycemia, ketonuria, and acidosis (pH between 7.25 and 7.4) in association with an impaired ability to retain oral fluids. Management requires evaluation and treatment by medical personnel in an emergency room and/or hospital setting. Suspension of oral fluid intake and intravenous fluid administration, combined with the administration of supplementary insulin, results in resolution of DKA. Potential precipitating or aggravating medical conditions (such as infections, trauma, etc.) must also be recognized, evaluated, and treated, especially when the individual fails to respond to routine management.

Severe DKA is characterized by severe acidosis (pH < 7.25), dehydration, hyperglycemia, ketosis, and a variety of signs and symptoms that may include Kussmaul respirations, mental obtundation, and unconsciousness. Dehydration may be severe and cause shock. Precipitating or aggravating medical conditions (such as infections, drug or alcohol ingestion, trauma, etc.) may result in additional signs and symptoms and, occasionally, may complicate management.

Treatment of severe DKA can be divided into 3 "phases": (1) resuscitation, (2) correction of acid-base, glucose, and electrolyte abnormalities, and (3) transition to daily treatment regimen. During the resuscitation phase the "ABCs" (airway, breathing, circulation) are addressed by securing the airway, ensuring adequate ventilation, and correcting shock with intravenous volume expanders. Intravenous fluids and insulin are used to correct acid-base, glucose, and electrolyte abnormalities. The use of bicarbonate should be considered when acidosis is especially severe (pH < 7.1). Once stable, the child can be initiated or restarted on his usual treatment program, with ongoing diabetes education and behavioral support services provided as needed. As mentioned above, potential precipitating and/or aggravating factors (infections, drug ingestions, etc.) need to be addressed and treated during the course of management of DKA.

There is a lack of consensus regarding the type of fluid that should be used in the treatment of DKA, the use of bicarbonate, and factors associated with acute complications, including cerebral edema.[1-3] The reader is referred to the referenced manuscripts for a detailed discussion of these issues. However, most individuals are in agreement with the concept that prevention of DKA is the ultimate goal of diabetes treatment. According to Dr. Neil White,[2] "Involvement and close follow-up by a multidisciplinary team of health care professionals with experience in dealing with diabetes in children and adolescents is the best way to avoid DKA."