Makindo Medical Notes

Initial Assessment

• History & Physical Examination: Assess symptoms such as vomiting, abdominal pain, dehydration, lethargy, and deep breathing (Kussmaul respiration). Evaluate hydration status, level of consciousness, and any infections as a possible precipitating factor.
• Vital Signs: Measure heart rate, respiratory rate, blood pressure, and oxygen saturation.

BSPED Guideline

• The ISPAD definition for DKA with acidosis and a bicarbonate of <15 mmol/l or a pH <7.3, and ketones of >3.0 mmol per litre has been adopted

BSPED Classify severity

• Mild DKA – venous pH 7.2- 7.29 or bicarbonate < 15 mmol/l. Assume 5% dehydration
• Moderate DKA – venous pH 7.1-7.19 or bicarbonate < 10 mmol/l. Assume 5% dehydration
• Severe DKA – venous pH less than 7.1 or serum bicarbonate < 5 mmol/l. Assume 10% dehydration

Careful management of fluid administration remains an important part of the management of diabetic ketoacidosis because of the risk of cerebral oedema but there is increased emphasis on the importance of treating shock and restoring appropriate circulatory volume

Investigations

• Blood Tests: Blood glucose, blood gases (pH, bicarbonate), electrolytes (sodium, potassium), urea, and creatinine levels.
• Urine Tests: Test for ketones using a dipstick.
• Other Tests: In some cases, tests for infections may be needed (e.g., chest X-ray or culture samples).

Initial Management

• Airway Ensure that the airway is patent and if the child is comatose, insert an airway. If consciousness reduced or child has recurrent vomiting, consider inserting N/G tube, aspirate and leave on open drainage.
• Breathing Give 100% oxygen by face-mask.
• Circulation Insert IV cannula and take blood samples (see below). Cardiac monitor for T waves (peaked in hyperkalaemia). Measure blood pressure and heart rate
• Shocked patients require adequate fluid volume resuscitation. A fluid bolus of 10ml/kg should be given if shocked, in line with recent UK Resuscitation Council guidance. Repeated 10ml/kg boluses should be considered if patient remains shocked until they are adequately resuscitated. Shocked patients will require high dependency care and should be discussed with the most senior paediatrician or intensivist available at the earliest opportunity
• Not shocked: All children and young people with mild, moderate or severe DKA who are not shocked and are felt to require IV fluids should receive a 10 ml/kg 0.9% sodium chloride bolus over 30 minutes. (PlasmaLyte 148 is used by some teams in the UK for initial resuscitation in place of 0.9% sodium chloride but its use was not recommended by NICE due to insufficient evidence)
• Insulin Therapy: Start low-dose insulin infusion after fluid resuscitation. Avoid bolus insulin.
• U&E Monitor and correct potassium levels, as insulin can drive potassium into cells, causing hypokalaemia.
• Monitoring: Monitor blood glucose, electrolytes, and blood gases regularly (every 1-2 hours initially). Ensure careful neurological assessment to detect early signs of cerebral oedema.
• Treat Underlying Causes: If an infection or another underlying cause triggered DKA, treat it alongside DKA management.
• Transition to Subcutaneous Insulin: When the child is clinically stable, ketones have cleared, and they can eat and drink, transition to subcutaneous insulin therapy.
• Education and Follow-up: Provide education to both the child and their caregivers about diabetes management, DKA prevention, and recognizing early symptoms. Ensure appropriate follow-up with a paediatric diabetes team.

Death from DKA

• Cerebral oedema This is unpredictable, occurs more frequently in younger children and newly diagnosed diabetes and has a mortality of around 25%. The causes are not known and evolution of cerebral oedema can be unpredictable. The management of cerebral oedema is covered within the guideline.
• Hypokalaemia This is preventable with careful monitoring and management
• Aspiration pneumonia Use a naso-gastric tube in semi-conscious or unconscious children
• Inadequate resuscitation It is important to ensure that children with DKA receive adequate resuscitation if they are shocked. Inadequate resuscitation is likely to increase the risk of brain injury.Cerebral perfusion is influenced both by the circulatory perfusion pressure (blood pressure) and the intracranial pressure in incipient cerebral oedema

References

• BSPED Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis - 2021