Diabetic ketoacidosis

• What is diabetic ketoacidosis?


  Life-threatening medical emergency

  Characterised by hyperglycaemia, acidosis (bicarb < 15 mmol/L or pH < 7.3) & ketonaemia (> 3.0 mmol/L)

  Most common way that children with a new diagnosis of T1DM present
• Pathophys - DKA


  Occurs in T1DM when not producing enough insulin & not injecting enough insulin -> ketoacidosis, dehydration & K+ imbalance

  Cells have no fuel -> ketogenesis (use fatty acids for fuel -> production of ketones) -> overtime ketone acids make blood acidic -> ketoacidosis

  Hyperglycaemia -> overwhelms kidneys -> glucose in urine -> draws water into kidney tubules -> polyuria -> dehydration & polydipsia

  Insulin drives K+ into cell -> no insulin = serum K+ increases

  So, when insulin is started, pts can develop severe hypokalaemia very quick -> fatal arrhythmias
• What are children with DKA at risk of?


  Cerebral Oedema

  Due to rapid correction of dehydration & hyperglycaemia -> causes rapid shift in water from extracellular space to intracellular space into brain cells
• What can be used to show signs of cerebral odema?


  GCS monitoring

  Look for signs of cerebral oedema (headaches, altered behaviour, bradycardia or changes to consciousness)
• What are the management options of cerebral oedema?


  Slowing IV fluids

  IV mannitol

  IV hypertonic saline
• What are the RFs of DKA?


  Infection

  Discontinuation of insulin

  Inadequate insulin

  New onset diabetes

  Acute illness (MI, sepsis, pancreatitis)

  Physiological stress (pregnancy, surgery, trauma)

  Hx of diabetes
• What is the classification of DKA?


  Mild

  • pH 7.1-7.29
  • bicarb < 15 mmol/L
  • dehydration 5%

  Moderate

  • pH 7.1-7.19
  • bicarb < 10 mmol/L
  • dehydration 5%

  Severe

  • pH < 7.1
  • bicarb < 5 mmol/L
• What are the signs & symptoms of DKA?


  Fruity smelling breath

  Vomiting

  Weight loss

  Dehydration (secondary to polydipsia & polyuria)

  Abdo pain

  Deep, sighing respiration (Kussmaul respiration)

  Signs of hypovolaemic shock

  Altered mental status (inc. drowsiness or coma)
• What are the Inx for DKA?


  Blood glucose (> 11.1 mmol/L)

  Blood ketones (> 3 mmol/L)

  U&Es

  Blood gas (ABG/VBG/CBG)

  Urinary glucose & ketones

  Blood cultures (if evidence of infection)

  Cardiac monitoring
• What is the diagnostic criteria of DKA?


  Hyperglycaemia (> 11 mmol/L)

  Ketosis (> 3 mmol/L)

  Acidosis (pH < 7.3)
• What are the DDx of DKA?


  Lactic acidosis

  Starvation ketosis

  Inborn errors of metabolism

  Sepsis
• What is the treatment of DKA?


  A-E approach

  IV fluids (10 ml/kg over 15 mins) -> repeat as needed until reached 40 ml/kg

  • may need to consider hypokalaemia

  Insulin infusion (0.1 units/kg/hour) 1 hour after starting IV fluids

  Monitor hourly blood glucose & ketones, neurological obs & fluid balance
• When can discharge for DKA be considered?


  Child is eating & drinking

  Stabilised on subcutaneous insulin regime
• What are the possible complications of DKA?


  Cerebral oedema

  Hypokalaemia

  Aspiration pneumonia

  Venous thromboembolism

  Inadequate resuscitation

  Hypoglycaemia