Overview/Definition
Definition:
• Diabetic Ketoacidosis (DKA) is life-threatening acute complication of type 1 diabetes mellitus characterized by hyperglycemia >250 mg/dL, metabolic acidosis (pH <7.3, bicarbonate <15 mEq/L), and ketosis
Leading cause of morbidity and mortality in children with diabetes, accounting for 70% of diabetes-related deaths in children <10 years.
Epidemiology:
• DKA occurs in 25-40% of children at diabetes diagnosis in India, higher rates in younger children and lower socioeconomic groups
Annual DKA incidence 1-5% in established diabetics
Mortality rate 0.15-0.3% in developed countries, higher in developing nations
Peak age at presentation 10-14 years.
Age Distribution:
• Infants (<2 years): Higher risk of cerebral edema, often presents at diabetes diagnosis
Children (2-12 years): Classic presentation more common, dehydration prominent
Adolescents (12-18 years): Higher rates due to insulin omission, eating disorders, psychological stress
Young adults: Transition period with medication non-adherence.
Clinical Significance:
• Critical topic for DNB Pediatrics and NEET SS examinations focusing on fluid resuscitation protocols, insulin administration, electrolyte management, and cerebral edema prevention
Understanding pathophysiology, diagnostic criteria, treatment algorithms, and complications essential for emergency management.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Extremely rare, usually associated with neonatal diabetes or maternal diabetes
Higher fluid losses per body weight
Greater risk of cerebral edema due to immature blood-brain barrier
More conservative fluid resuscitation recommended
Close monitoring in NICU setting required.
Infant:
• Infants (1-24 months): High proportion of new-onset diabetes presentations
Vomiting, dehydration, failure to thrive common
Difficulty recognizing symptoms leads to delayed diagnosis
Higher cerebral edema risk
More conservative fluid replacement (1.5 times maintenance) recommended.
Child:
• Children (2-12 years): Classic DKA presentation with polyuria, polydipsia, weight loss
Better cooperation for clinical assessment
Standard fluid protocols applicable
Monitor for cerebral edema carefully
Educational component important for family.
Adolescent:
• Adolescents (12-18 years): Higher rates of DKA due to psychosocial factors, insulin omission
Eating disorders common comorbidity
Adult-like presentation patterns
Risk-taking behavior affects compliance
Transition to adult care considerations.
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Clinical Presentation
Symptoms:
• Early symptoms: Polyuria, polydipsia, polyphagia, weight loss over days to weeks
DKA symptoms: Nausea, vomiting, abdominal pain, altered mental status
Respiratory: Kussmaul breathing (deep, rapid respirations)
Systemic: Weakness, fatigue, dehydration signs.
Physical Signs:
• Dehydration signs: Dry mucous membranes, poor skin turgor, sunken eyes, delayed capillary refill
Cardiovascular: Tachycardia, hypotension in severe cases
Respiratory: Kussmaul respirations, acetone breath odor
Neurological: Altered consciousness, confusion, coma in severe cases.
Severity Assessment:
• Mild DKA: pH 7.25-7.30, bicarbonate 15-18 mEq/L, alert mental status
Moderate DKA: pH 7.0-7.24, bicarbonate 10-14 mEq/L, drowsy/stuporose
Severe DKA: pH <7.0, bicarbonate <10 mEq/L, coma
Assess degree of dehydration: 5-10% (mild-severe).
Differential Diagnosis:
• Other causes of metabolic acidosis: Salicylate poisoning, methanol/ethanol ingestion, uremia, lactic acidosis
Acute abdomen: Appendicitis, gastroenteritis
Respiratory conditions: Pneumonia, asthma
Other endocrine: Adrenal crisis, thyrotoxicosis.
Diagnostic Approach
History Taking:
• Diabetes history: Known diabetes, medication compliance, recent illness, insulin dosing errors
Precipitating factors: Infection, stress, dietary indiscretion, medication non-adherence
Family history: Diabetes, autoimmune diseases
Recent symptoms: Duration, severity, associated factors.
Investigations:
• Blood glucose: Typically >250 mg/dL (>13.9 mmol/L)
Arterial blood gas: pH <7.3, bicarbonate <15 mEq/L, anion gap >12
Ketones: Blood β-hydroxybutyrate >3.0 mmol/L or urine ketones large
Electrolytes: Sodium, potassium, chloride, calculate anion gap
Complete blood count, urinalysis, blood cultures.
Normal Values:
• Normal blood glucose: 70-100 mg/dL fasting
Normal pH: 7.35-7.45
Normal bicarbonate: 22-28 mEq/L
Normal anion gap: 8-12 mEq/L
Normal potassium: 3.5-5.0 mEq/L
Normal sodium: 135-145 mEq/L
β-hydroxybutyrate <0.6 mmol/L normal.
Interpretation:
• DKA diagnosis: Hyperglycemia + metabolic acidosis + ketosis
Anion gap metabolic acidosis: Calculate anion gap [Na+ - (Cl- + HCO3-)]
Severity based on pH and bicarbonate levels
Effective osmolality: 2[Na+] + glucose/18, used for fluid calculations.
Management/Treatment
Acute Management:
• Initial assessment: Airway, breathing, circulation, consciousness level
IV access: Two large-bore IVs, central access if needed
Fluid resuscitation: Normal saline 10-20 ml/kg over 1-2 hours if shocked
Insulin therapy: Regular insulin 0.05-0.1 units/kg/hr IV after initial fluid bolus.
Chronic Management:
• Transition to subcutaneous insulin when: pH >7.3, bicarbonate >15 mEq/L, anion gap <12, tolerating oral intake
DKA education: Sick day management, ketone monitoring, when to seek help
Diabetes management: Long-term insulin regimen, glucose monitoring, lifestyle modifications.
Lifestyle Modifications:
• Diabetes education: Carbohydrate counting, insulin adjustment, blood glucose monitoring
Sick day rules: Never stop insulin, test ketones, maintain hydration
Exercise guidelines: Monitor glucose before/after exercise
Diet counseling: Consistent carbohydrate intake, meal timing.
Follow Up:
• ICU monitoring during acute DKA treatment: Hourly vital signs, glucose, electrolytes
Endocrinology follow-up within 1-2 weeks post-discharge
Diabetes educator involvement for comprehensive care
Long-term monitoring: HbA1c every 3 months, screening for complications.
Age-Specific Dosing
Medications:
• Insulin regular: 0.05-0.1 units/kg/hr IV infusion (lower dose for children <5 years)
Fluid replacement: Deficit + maintenance + ongoing losses
Initial fluid: Normal saline 10-20 ml/kg if shocked, then maintenance at 1.5x for children, 1.25x for adolescents
Switch to 0.45% saline when sodium >150 mEq/L.
Formulations:
• Regular insulin: 100 units/ml vials for IV infusion, dilute 50 units in 50 ml normal saline (1 unit/ml)
Maintenance fluids: 0.45% saline with 5-10% dextrose when glucose <250-300 mg/dL
Potassium replacement: KCl 40 mEq/L in maintenance fluids when urine output established.
Safety Considerations:
• Cerebral edema risk: Avoid rapid changes in serum osmolality, excessive fluid administration
Monitor for signs: Headache, vomiting, altered consciousness, bradycardia
Hypokalemia: Check potassium before insulin, replace aggressively
Hypoglycemia: Start dextrose when glucose approaches 250-300 mg/dL.
Monitoring:
• Frequent monitoring: Glucose hourly, electrolytes every 2-4 hours, arterial blood gas every 4-6 hours
Neurological assessment: Glasgow Coma Scale, pupil size and reactivity
Fluid balance: Hourly urine output, daily weights
Cardiac monitoring: Continuous ECG for potassium changes.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention: Early diabetes diagnosis through screening
Secondary prevention: Proper diabetes education, sick day management, regular follow-up
DKA prevention education: Never stop insulin, ketone monitoring during illness, when to contact healthcare provider.
Vaccination Considerations:
• Annual influenza vaccination recommended
Routine immunizations as per schedule
Consider pneumococcal vaccination
During acute illness, delay non-urgent vaccinations until stable
Monitor glucose levels closely after vaccination as stress response may affect control.
Follow Up Schedule:
• Post-DKA: Endocrinology within 1-2 weeks, diabetes educator session
Routine diabetes care: Every 3-4 months with HbA1c monitoring
Annual screening: Retinopathy, nephropathy, neuropathy (after 5 years duration or at puberty)
Emergency action plan review quarterly.
Monitoring Parameters:
• Glycemic control: HbA1c target <7% for most children
Growth parameters: Height, weight, BMI monitoring
Complications screening: Annual eye exams, microalbumin, lipid profile
Psychosocial assessment: Depression screening, family functioning, quality of life measures.
Complications
Acute Complications:
• Cerebral edema: Most serious complication (0.5-1% incidence), higher in younger children
Signs: Headache, vomiting, altered consciousness, bradycardia, hypertension
Hypokalemia: Due to insulin therapy, can cause cardiac arrhythmias
Hypoglycemia: From excessive insulin or inadequate glucose administration.
Chronic Complications:
• Recurrent DKA: Often due to insulin omission, eating disorders, psychological issues
Long-term diabetes complications: Retinopathy, nephropathy, neuropathy
Growth complications: Poor linear growth with recurrent DKA
Psychological impact: Anxiety, depression, diabetes distress.
Warning Signs:
• Cerebral edema: Headache, vomiting, altered mental status, abnormal neurological signs, bradycardia
Treatment failure: Persistent acidosis, glucose not responding appropriately
Electrolyte abnormalities: Cardiac rhythm changes, muscle weakness, altered consciousness.
Emergency Referral:
• Immediate pediatric ICU referral for: Severe DKA, altered consciousness, signs of cerebral edema
Neurology consultation for suspected cerebral edema
Endocrinology consultation for all DKA cases
Social services if medication non-adherence or family dysfunction suspected.
Parent Education Points
Counseling Points:
• DKA is serious but preventable complication of diabetes
Importance of never stopping insulin even during illness
Sick day management rules and when to check ketones
Recognition of warning signs requiring immediate medical attention
Long-term diabetes management prevents DKA recurrence.
Home Care:
• Sick day rules: Continue insulin, test ketones every 4 hours during illness, maintain hydration
Blood glucose monitoring: Test every 2-4 hours during illness
Ketone monitoring: Urine or blood ketones, know when levels require medical attention
Medication storage and administration techniques.
Medication Administration:
• Insulin administration: Proper injection technique, site rotation, storage requirements
Never stop insulin even if not eating
Adjust doses based on blood glucose and ketones during illness
Emergency supplies: Always have extra insulin, supplies available
Glucagon kit for severe hypoglycemia.
When To Seek Help:
• Immediate medical attention for: Vomiting preventing fluid intake, blood glucose >400 mg/dL with ketones, signs of dehydration
Moderate/large ketones with illness
Persistent vomiting, abdominal pain, difficulty breathing
Any concerns about child's condition during illness.