management of child with diabetic ketoacidosis
Last reviewed 01/2018
Most paediatric units will have a protocol for management of children in diabetic ketoacidosis. An important principle is proper recognition and adequate resuscitation of the child before subtle management of the underlying diabetes is tackled.
Assess and record the following
- degree of dehydration
- mild, 3% - is only just clinically detectable
- moderate, 5% - dry mucous membranes, reduced skin turgor
- severe, 8% - above with sunken eyes, poor capillary return
- shock - may be severely ill with poor perfusion, thready rapid pulse (reduced blood pressure is not likely and is a very late sign)
- N.B. over estimation of degree of dehydration is dangerous, hence do not use more than 8% dehydration in calculations
- conscious level
- institute hourly neurological observations including Glasgow coma score whether or not drowsy on admission
- if in coma on admission, or there is any subsequent deterioration
- consider transfer to pediatric intensive care unit (PICU) / high-dependency unit (HDU) if available
- consider initiating cerebral oedema management (if high level of suspicion, start treatment prior to transfer)
- N.B. coma is directly related to degree of acidosis, but signs of raised intracranial pressure suggest cerebral oedema
- look for evidence of
- cerebral oedema - headache, irritability, slowing pulse, rising blood pressure, reducing conscious level ( papilloedema is a late sign)
- infection
- ileus
Child should be weighed (if unable due to the clinical condition, use the most recent clinic weight as a guideline or an estimated weight from centile charts). If body surface area is used for fluid therapy calculations, measure height or length to determine surface area
Consider PICU or HDU for the following
- severe acidosis pH<7.1 with marked hyperventilation
- severe dehydration with shock
- depressed sensorium with risk of aspiration from vomiting
- very young (under 2 years)
- staffing levels on the wards are insufficient to allow adequate monitoring
The following observations should be carried out and documented during the entire treatment period:
- strict fluid balance with hourly fluid input and output (if required catheterise young/sick children)
- hourly capillary blood glucose measurements (these may be inaccurate with severe dehydration/acidosis but useful in documenting the trends. Do not rely on any sudden changes but check with a venous laboratory glucose measurement)
- capillary blood ketone levels every 1-2 hours, if unavailable urine testing for ketones
- hourly BP and basic observations
- twice daily weight; can be helpful in assessing fluid balance
- hourly or more frequent neurological observations initially
- symptoms of headache, or slowing of pulse rate, or any change in either conscious level or behaviour in the child
- any changes in the ECG trace, especially T wave changes suggesting hyper- or hypokalaemia (1,2)
Reference: