1. MANAGEMENT OF DIABETIC KETOACIDOSIS IN CHILDREN
S.V. DELPORT
Paediatric Endocrine and Diabetes Unit

2. DIABETIC KETOACIDOSIS
Type 1 DM – epidemic
Current trends in RSA
All population groups
Peaks 4-6 years and years
80 new cases/year (RCCH or GSH)
85% in DKA

3. DIABETIC KETOACIDOSIS
Deficiency of circulating insulin
Increased counter-regulating hormones
Catecholamines
Glucogon
Cortisol
Growth hormone
Increased catabolic state
Increased glucose production
Impaired glucose utlilization

4. CONSEQUENCES Hyperglycaemia Osmotic diuresis Stress hormone production
Dehydration
Electolyte imbalance
Stress hormone production
Inducing further insulin resistance
Ketosis
Acidosis

5. CLINICAL MANIFESTATION OF DKA
Dehydration
Rapid, sighing (Kussmaul) breathing
Nausea, vomiting, abdominal pain
Progressive obtundation
Fever (presence of infection)

6. CLINICAL MANIFESTATION OF DKA (Biochemical)
Hyperglycaemia > 11mmol/L
Venous blood gas
PH < 7.3
Bicarbonate < 15 mmol/L
Ketonaemia/ketonuria

7. ASSESSMENT OF SEVERITY
Mild
Moderate
Severe
haemodynamic
status
normal perfusion
normal BP
BP (poor peripheral pulses)
perfusion
hydration
dehydration 5%
dehydration > 10%
dehydration > 10%
Level of consciousness
fully conscious, alert
drowsy
depressed level of consciousness
acidosis
pH > 7.3
pH < 7.3
pH <7.1

8. GOALS OF THERAPY Correct dehydration
Correct acidosis & reverse ketosis
Restore blood glucose to near normal
Avoid complications of therapy
Identify and treat precipitating event

9. MANAGEMENT OF DKA Fluid Therapy
Resuscitation Oxygen 100% by face mask
Treat shock first Normal saline 0.9% 10 ml / kg over 10 – 30 minutes Reassess. Repeat if peripheral pulses remain poor
Insert nasogastric tube if there is vomiting ± impaired consciousness
If the referral centre is more than 1 hour away, 0.9% saline should continue at 10 ml/ kg/ hr
for 1– 2 hours, then at a rate of 5 ml/ kg/ hr
Proceed to step 2 when hypovolaemia corrected.

10. Fluid Therapy continued
2. Rehydration requirements = Maintenance + Deficit + excess urine losses (if known)
Maintenance yrs ml/kg/24 hrs
ml/kg/24 hrs
ml/kg/24 hrs
ml/kg/24 hrs
adult (>15) ml/kg/24 hrs
+ Deficit % dehydrated ml/kg over 48 hrs
10 % dehydrated ml/kg over 48 hrs
+ Excess urine losses replace urine losses in excess of 2 ml/kg/hour = urine output (ml/kg/hr) – 2 ml/kg/hour
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3. Reassess patient and review fluid therapy calculations frequently
Note: Children < 5% dehydrated, with a pH ³ 7.3, who are clinically well, may tolerate oral rehydration and subcut insuli

11. MANAGEMENT (cont) Insulin therapy Insulin infusion
1-2 hours after fluids
once shock corrected
Actrapid HM or Humulin R
Bolus NOT recommended
When infusion not possible
hourly or 2 hourly
short or rapid acting analog

12. INSULIN INFUSION Optimal method:
Continuous low-dose IV insulin infusion by syringe pump, not by gravity controller
0.1 units/kg/hour Consider 0.05 units/kg/hour if < 5 years of age
Calculation:
For 0.1units/kg/hr patient weight <25kg : mix 25units insulin solution in 100ml voluven/saline run
insulin solution at (0.4 x patient's mass in kg) ml/hr
patient weight >25kg : mix 50units insulin solution in 100 ml voluven/saline run
insulin solution at (0.2 x patient's mass in kg) ml/hr

13. MANAGEMENT (cont) Potassium Phosphate Acidosis
start after resuscitation
Serum K < 4.5
No elevated Ts on ECG
Phosphate
falls once treatment started
Depleted by diuresis
Insulin promotes entry to cells
Acidosis
fluid
no bicarbonate

14. MONITORING BG – hourly ward glucometer
2-4 hour VBG, glucose, U & E, ketones, Pi
Urine volume
LOC (GCS – children’s)
BP, RR, HR, hydration
ECG
Treatment (IVF, K, Pi, Insulin)

15. MORTALITY and MORBIDITY
DKA mortality 0.15% to 0.3%
Cerebral oedema 60% to 80% DKA deaths
Local experience
0.07 (12 years: 2/2880)
100% cerebral oedema
10% - 25% residual morbidity

16. CEREBRAL OEDEMA Incidence 0.5 – 0.9% Mortality 21-24% Pathogenesis
Increased risk – demographics
Younger age
Hyponatraemia at onset
Longer duration of symptoms

17. CEREBRAL OEDEMA Risk factors at diagnosis / during treatment
Greater hypocapnia
Elevated urea
More sever acidosis at presentation
Bicarbonate
Attenuated rise in Na
Greater volume of fluid in first 4 hours
Insulin bolus or in 1st hour

18. CEREBRAL OEDEMA Warning signs and symptoms Headache and reduced HR
Change in neurological status
Specific neurological signs
Rising BP
Decreased O2 saturation

19. TREATMENT of CEREBRAL OEDEMA
Reduce rate of fluid administration
Give mannitol g/kg over 20 minutes (repeat 30 minutes to 2hrs)
Hypertonic saline (3%) 5-10ml/kg
Elevate head of bed
IPPV with hyperventilaton

20. DKA – KEY POINTS Caused by insulin deficiency
Managed in centre with expertise
Begin fluid replacement before starting insulin therapy
Volume expansion only to restore peripheral circulation
Subsequent fluid should rehydrate evenly over 48 hours
Begin insulin 1-2 hours after starting fluid replacement therapy

21. DIABETIC KETOACIDOSIS