Chapter 76

• Diabetic ketoacidosis (DKA) is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.
• DKA is often insidious in onset with slow progression of the illness.
• Definition of DKA by biochemical criteria includes the following:
• Hyperglycemia: Blood glucose > 200 mg/dL
• Venous pH < 7.3 or bicarbonate < 15 mmol/L
• Ketonemia and ketonuria
• In type 2 diabetes mellitus, hyperglycemic hyperosmolar state (HHS) can occur and is defined by the following:
• Plasma glucose concentration > 600 mg/dL
• Arterial pH > 7.30
• Serum bicarbonate > 15 mmol/L
• Small ketonuria and absent or mild ketonemia
• Serum osmolarity ≥ 320 mOsm/kg
• Stupor or coma

Treatment of diabetic ketoacidosis (DKA) consists of rapid assessment, replacement of the patient's fluid and electrolyte deficit, and reversal of the central pathophysiologic process by the administration of insulin.

The initial fluid resuscitation is with normal saline at a dose of 10 to 20 mL/kg over 1 to 2 hours. After the initial bolus, the patient's cardiovascular status is reevaluated and a second bolus may be administered.

An initial bolus of insulin is unnecessary and can increase the risk for cerebral edema. The insulin infusion starting dose is 0.1 U/kg/h and this should continue till resolution of DKA (pH > 7.3, bicarbonate > 15 mmol/L).

Potassium replacement therapy is started once normal or low serum potassium is ensured and urine output is established. The usual dose of potassium is twice-daily maintenance or 3 to 4 mEq/kg per 24 hours provided as 40 mEq/L in the IV fluids, with half as potassium chloride and half as potassium phosphate.

Cerebral edema occurs in 0.5% to 0.9% of DKA patients and the mortality rate is 21% to 24%. The predisposing factors are younger age, new onset diabetes, and longer duration of symptoms.

Newborns and young infants with hypoglycemia may be asymptomatic or may manifest nonspecific symptoms. Older children exhibit more classic symptoms of hypoglycemia, including sweating, tachycardia, tremor, anxiety, tachypnea, and weakness.

Treatment of hypoglycemia

• In newborns, give 10% dextrose 2 mL/kg (0.2 g/kg) as a bolus, followed by infusion at 6 to 9 mg/kg/min
• In children, give 10% dextrose at 5 mL/kg (0.5 g/kg) as a bolus, followed by continuous infusion at 6 to 9 mg/kg/min
• If an IV line is not possible, then give glucagon 0.03 mg/kg (maximum dose 1 mg) subcutaneously

Admission of the hypoglycemic patient is indicated when there is no obvious cause, toxic ingestion as with oral hypoglycemic agents is suspected, administration of long-acting insulin was the cause, and if there are persistent neurological deficits.

DKA is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.

### Epidemiology

The annual incidence of DKA in the United States ranges from 4.6 to 8 episodes per 1000 ...

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