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DEFINITION AND DIAGNOSIS

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Diabetic ketoacidosis (DKA) mainly affects children with type 1 diabetes mellitus (T1DM) and is caused by a deficiency in circulating insulin levels and elevations in other hormones like glucagon and cortisol. This, in turn, leads to:

  • Impaired glucose consumption by the peripheral tissues with elevations in plasma glucose levels

  • Increased glucose production by the liver through gluconeogenesis and glycogenolysis

  • Increased serum osmolality

  • Increased lipolysis with production of ketone bodies (ß-hydroxybutyrate) and resultant ketonemia

  • Profound anion gap metabolic acidosis

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The hyperglycemia and acidosis associated with DKA result in a profound osmotic diuresis, significant dehydration, glycosuria, ketonuria, ketonemia, and electrolyte disturbances.

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SIGNS AND SYMPTOMS OF ACUTE DKA CAN INCLUDE:

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  • Polyuria/increased urination

  • Polydipsia/increased thirst

  • Vomiting and dehydration

  • Abdominal pain

  • Irregular respirations (Kussmaul breathing: large, deep, gasping breaths)

  • Weakness and lethargy

  • Altered mental status and confusion

  • Loss of consciousness or coma

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THE DIAGNOSTIC CRITERIA FOR DKA INCLUDE:

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  • Hyperglycemia (serum glucose >250–300 mg/dL)

  • Significant venous acidosis (pH <7.3)

  • Serum bicarbonate levels ≤15 mmol/L

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DKA IS GENERALLY CATEGORIZED ACCORDING TO THESE pH AND BICARBONATE VALUES (Table 59-1).

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Table Graphic Jump Location
TABLE 59-1

Classification of DKA severity

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INCIDENCE OF DKA

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  • As mentioned, DKA occurs more commonly in patients with T1DM but has been seen in older children with type 2 diabetes mellitus. DKA at the onset of T1DM occurs more frequently in:

    • Young children (age <4 years)

    • Children of lower socioeconomic status

    • Children without a significant family history of diabetes

  • Children with known relatives with T1DM are more frequently evaluated by clinicians and are less likely to present in DKA.

  • Children with known T1DM have a 1% to 10% risk of having an episode of DKA/year

  • Children at higher risk for DKA after the diagnosis of T1DM are:

    • Peripubertal/adolescent girls

    • Children from lower-income households

    • Children with mood or eating disorders

    • Children with poor self or parental compliance to medical therapy

  • DKA can often be precipitated by:

    • An intercurrent illness (e.g., viral or bacterial infection)

    • Inadequate insulin administration

    • Corticosteroid or diuretic use

    • Exacerbation of another underlying disease that puts the body under a stress state (e.g., pancreatitis, trauma, heart disease)

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MANAGING DKA

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In known T1DM patients with evidence of urinary ketones or elevated glucose without significant acidosis, care can be managed at home in close contact with a pediatric endocrinologist.

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Children with new-onset T1DM or moderate to severe DKA should be considered for inpatient or pediatric intensive care admission.

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INITIAL STABILIZATION OF PATIENTS IN DKA IN AN ACUTE CARE SETTING SHOULD INCLUDE:

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  1. Establishing a protocolized monitoring system:

    • Hourly vital sign monitoring of heart rate, ...

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