Paediatrics: Diabetic ketoacidosis

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a diabetic emergency and such patients can die from hypovolaemic shock, cerebral oedema, hypokalaemia, or aspira-tion 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 altered level of consciousness require careful supervision and treatment. Some patients may need 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 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.