Diabetic Ketoacidosis in the Pediatric Emergency Department

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Key points

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    Despite advances in research and treatment, the incidence of pediatric-onset diabetes and diabetic ketoacidosis is increasing.

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    Diabetes mellitus is one of the most common chronic pediatric illnesses and, along with diabetic ketoacidosis, is associated with significant cost and morbidity.

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    DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves proper fluid resuscitation with insulin and electrolyte replacement under constant monitoring for

Epidemiology

In 2010, the Centers for Disease Control and Prevention estimated that 215,000 Americans younger than 20 years of age were diabetic.1 Despite significant advances in diabetes management, the incidence of DKA and diabetes complications remains high, probably as a result of the alarming increase in childhood obesity and its direct link to diabetes. The incidence of DKA at the time diabetes is diagnosed varies by geographic location, ranging from 12% to 80%; approximately one-third of type 1

Pathophysiology

Insulin is the primary hormone of blood glucose regulation. It is responsible for increasing peripheral glucose uptake and stopping hepatic gluconeogenesis. As blood glucose levels increase, counter-regulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) play reciprocal roles with insulin in attempts to maintain glucose homeostasis. DKA results from an absolute or relative deficiency of insulin and the resulting excess of counter-regulatory hormones. Absolute insulin

Clinical presentation

DKA can develop quickly in patients with established diabetes, especially when it is related to insulin omission. However, when DKA acts as the first presentation of diabetes, the symptoms emerge over several days. Typical symptoms are the classic triad of polyuria, polydipsia, and weight loss with or without polyphagia. These symptoms are easy to miss in children who are wearing diapers and being fed by multiple caretakers. Abdominal pain, nausea, and vomiting are also common complaints.

Diagnosis

The biochemical criteria for DKA are as follows12, 25, 26, 27:

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    Hyperglycemia with blood glucose concentration greater than 200 mg/dL (>11 mmol/L)

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    Venous pH less than 7.3 or bicarbonate concentration less than 15 mmol/L

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    Ketonuria and ketonemia

The severity of DKA can be categorized as follows12, 25, 26, 27:

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    Mild: venous pH less than 7.3, HCO3 less than 15 mmol/L

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    Moderate: venous pH less than 7.2, HCO3 less than 10 mmol/L

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    Severe: venous pH less than 7.1, HCO3 less than 5 mmol/L

The basic initial

Emergency department management

Current practice guidelines are based on both evidence and consensus recommendations. First and foremost, pediatric resuscitation principles should be followed. Airway, breathing, and circulation should be secured. Intravenous access must be obtained. Aspiration precautions should be taken if the patient has an altered level of consciousness. Continuous cardiac monitoring and pulse oximetry are imperative to assess for arrhythmias secondary to hyperkalemia or hypokalemia and to ensure adequate

Complications

The most common complications of DKA are hypokalemia and hypoglycemia, which occur in response to treatment, as discussed previously. Thus, blood glucose and electrolyte concentrations must be monitored frequently throughout the course of DKA management. Cerebral edema, the most feared complication, is exclusive to pediatric patients with DKA. Almost no cases have been reported in patients older than 20 years of age.

Cerebral edema is a potentially devastating complication of pediatric DKA. It

Disposition

Established diabetics with mild DKA who are alert and tolerating oral fluids can be treated in the emergency department and discharged, provided they have close supervision at home, possess the proper medications and supplies, have been educated about insulin administration, have the ability to monitor their blood glucose level, and have access to close follow-up.27 Patients with new-onset diabetes must be admitted. Patients requiring IV rehydration over an extended period need to be admitted

Summary

Despite advances in research and treatment, the incidence of pediatric-onset diabetes and diabetic ketoacidosis is increasing. Diabetes mellitus is one of the most common chronic pediatric illnesses and, along with diabetic ketoacidosis, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment revolves around proper fluid resuscitation with insulin and electrolyte replacement under constant

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