Paediatrics: Diabetic ketoacidosis

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a diabetic emergency and such patients can die from hypovolaemic shock, cerebral oedema, hypokalaemia, or aspiration pneumonia. DKA is defined as:

• Hyperglycaemia (>11mmol/L).
• pH < 7.3.
• Bicarbonate <15mmol/L.
• Urinary ketones.

Patients who meet the above criteria, who are more than 5% dehydrated, or who have an altered level of consciousness require careful supervision and treatment. Some patients may need a referral to an intensive care unit (e.g. pH < 7.1, severe dehydration with shock, <2yrs of age).

Clinical assessment

• Degree of dehydration.
• Level of consciousness.
• Full examination for evidence of cerebral oedema, infection, and ileus.
• Weight.

Investigations

The key tests are as follows.

Blood

• FBC with differential.
• Serum electrolytes with urea and creatinine.
• Glucose.
• LFTs (transaminases).
• Arterial or capillary blood gas.
• Lactate level.
• Ketone level.

Urine

• Urinalysis.
• Ketones.
• Reducing substances.
• Organic and amino acids.
• Drug screen.

Monitoring

• Ensure the ABCs: after that, the form and type of monitoring will be dictated by the patient’s condition.
• CNS: follow the neurological state. If there is a headache or altered consciousness, treat as though raised ICP has developed.
• Continuous pulse oximetry and ECG monitoring: T-wave changes should alert you to hypokalaemia or hyperkalaemia.
• Intermittent BP monitoring.
• Hourly urine output: test for ketones.