QuestionSBA
QuestionChoice
This patient has presented with diabetic ketoacidosis, meeting the criteria of hyperglycaemia, acidosis and ketonaemia. A resuscitation fluid bolus of maximum 10-20ml/kg 0.9% normal saline should be given initially. It should not exceed this amount due to the increased risk of cerebral oedema. Subsequently, the maintenance fluid volumes should be calculated, and the volume deficit gradually replaced over the next 48 hours. The initial resuscitation fluid bolus should be subtracted from the maintenance fluid volume if the patient is not in shock
32138
a
400 ml bolus of 0.9% normal saline over 30 minutes
QuestionChoice
This is reserved for symptomatic hyponatraemia with a depressed level of consciousness and a high risk of cerebral oedema, which may occur if fluid administration is given too rapidly. **This should not be given without discussing with a senior first!** In diabetic ketoacidosis, the sodium levels should always be corrected for hyperglycaemia
32140
c
100 ml of 2.7% hypertonic sodium chloride over 15 minutes
QuestionChoice
This **should not** be given to children and young people with diabetic ketoacidosis. It should only be reserved for special situations in which the patient has compromised cardiac contractility caused by life-threatening hyperkalaemia or severe acidosis, and only after discussion with a senior. The initial metabolic acidosis should resolve upon treatment with intravenous fluids and an insulin infusion
32142
e
Intravenous sodium bicarbonate
QuestionChoice
This would be a suitable maintenance fluid regimen. Maintenance fluid volumes for children in DKA can be calculated as reccommended by the BPSED DKA guideline as: 100ml/kg/day for the first 10kg of bodyweight, 50ml/kg/day for weight between 10-20kg and then 20ml/kg/day for each additional kg above 20kg. For a 40kg boy, it would be (100ml x 10kg) + (50ml x 10kg) + (20ml x 20kg) = 1000ml + 500ml + 400ml = 1900ml over 24 hours
32139
b
1900 ml of 0.9% normal saline over 24 hours
QuestionChoice
This would be one of the treatments for hyperkalaemia. However, this should not be given as a fixed rate insulin infusion would be started for the initial management of diabetic ketoacidosis, which would drive potassium into cells and cause the K levels to fall. Potassium replacement should be added to bags of maintenance fluid unless the patient has K levels above the upper limit of normal
32141
d
Oral calcium resonium
QuestionComment
explanation sounds like 1900ml over 24 hours is correct?

19453
QuestionComment
think its describing that as an appropriate maintenance dose, but that this patient requires a bolus first as they are significantly dehydrated
22366
User
subscriber
Abscess Hypertension
QuestionComment
how do you work out they are significantly dehydrated?
27788
User
subscriber
Relapse Sclerosis
QuestionComment
@relapse sclerosis electrolyte imbalances, urea, and just general clinical presentation
54693
User
subscriber
Wilsons CT
User
subscriber
Kinase Metabolism
QuestionComment
40kg at 5 years old? Dude must be a giant. 
22946
User
subscriber
Anterior Gallbladder
QuestionComment
i think explanation is wrong, rapid correction of hyponatremia causes central pontine myelinolysis, not cerebral oedema. the latter is if you correct hypernatraemia too quickly which this patient is not at risk of
62153
QuestionComment
that is what I thought initially but apparently it is pseudohyponatraemia. Hyponatremia in DKA is often pseudohyponatremia, meaning the sodium level appears low on lab tests but is not truly low in the body. This occurs due to:

Hyperglycemia: High blood glucose levels cause water to shift out of cells and into the bloodstream (osmotic effect), diluting the sodium concentration. For every 100 mg/dL increase in blood glucose above normal, serum sodium decreases by approximately 1.6–2.4 mEq/L.
Corrected Sodium Calculation: To determine the true sodium level, you can use the following formula:
Corrected Sodium
=
Measured Sodium
+
0.016
×
(
Glucose
−
100
)
Corrected Sodium=Measured Sodium+0.016×(Glucose−100)
This adjustment accounts for the dilutional effect of hyperglycemia.
62194
User
subscriber
The Last Stylebender
User
subscriber
Vaccine Complement
QuestionComment
Cerebral oedema is a well-recognised and potentially fatal complication of diabetic ketoacidosis (DKA) in children. Its mechanism is not fully understood, but it is thought to arise from rapid fluid shifts caused by a sudden decrease in serum osmolality during treatment.
62486
User
administrator
Digital Teaching Fellow @ Quesmed
Concept
Chapter
# Summary
 

Diabetic ketoacidosis (DKA) is a serious complication often associated with type 1 diabetes, characterised by hyperglycaemia, ketonaemia, and acidosis. Key signs and symptoms include fruity-smelling breath, vomiting, dehydration, abdominal pain, hyperventilation, and altered mental status. Investigations include blood glucose and ketone measurements, blood gas analysis, urea and electrolytes, and possibly blood cultures if infection is suspected. Management strategies largely depend on the patient's condition, including hydration and insulin administration via various routes and in various volumes based on severity. The major complication is cerebral oedema, a rare but potentially fatal condition that might be caused by rapid correction of dehydration with IV fluids.
 

# Definition
 

Diabetic ketoacidosis (DKA) is a severe and life-threatening medical complication characterised by hyperglycaemia, acidosis and ketonaemia.

It is defined by acidosis (bicarbonate < 15 mmol/l or pH <7.3) and ketones >3.0 mmol/L. 
 

# Epidemiology
 

DKA is most commonly seen in individuals with type 1 diabetes. However, it can occur in those with type 2 diabetes under extreme stress or illness. The condition can be the first presentation of diabetes, especially type 1 diabetes in children and young adults.

It is more common in children under 5. 
 

# Aetiology
 

DKA can be precipitated by several factors, including infection, dehydration, stress, burns, fasting, or untreated type 1 diabetes. It is important to note that fever is not a typical part of DKA presentation. A raised temperature could indicate an underlying infection that may have triggered the DKA.

Risk factors include:

- Previous episodes of DKA 
- Peripubertal and adolescent girls 
- Comorbidities including psychiatric disorders
- Difficult home life
- Insulin pump therapy 


# Classification

- Mild: pH 7.1-7.29 or bicarbonate < 15 mmol/L. Dehydration 5%
- Moderate: pH 7.1-7.19 or bicarbonate < 10 mmol/L. Dehydration 5%
- Severe: pH <7.1 or bicarbonate < 5 mmol/L
 

# Signs and Symptoms
 

Patients with DKA may present with:
 

 -  Fruity-smelling breath (due to the presence of acetone)
 -  Vomiting
 -  Dehydration secondary to polydipsia and polyuria 
 -  Abdominal pain
 -  Deep, sighing respiration (Kussmaul respiration)
 -  Signs of hypovolaemic shock
 -  Altered mental status, including drowsiness or coma
 

# Differential Diagnosis
 

The main differential diagnoses for DKA in children include:
 
 -  **Lactic Acidosis**: This may present with rapid breathing, abdominal pain, and altered mental status. The patient may have a history of severe illness or sepsis, hepatic failure or metformin use.
 -  **Starvation Ketosis**: This usually presents with weight loss, nausea, and clear mental status. The condition is mild, with low-level ketonaemia.
 -  **Inborn errors of metabolism**: Tend to present earlier in life with metabolic disturbances or failure to thrive. 
 -  **Sepsis**: The child will be generally unwell, with a high or low temperature, hypotension and tachycardia. 
 

# Investigations
 

Diagnosis of DKA involves assessment of clinical features along with:
 

 -  Blood glucose (>11.1mmol/L)
 -  Blood ketones (>3mmol/L)
 -  Urea and electrolytes
 -  Blood gas analysis
 -  Urinary glucose and ketones
 -  Blood cultures (if evidence of infection)
 -  Cardiac monitoring/ECG (for any ischaemic changes or changes secondary to hypokalaemia)
 

Note that hyperglycaemia may not always be present in DKA.
 

# Management
 

Management of DKA should be based on the A to E approach followed by the following treatments: 

 -  IV fluids (initial bolus of 10ml/kg 0.9% NaCl, even if the patient is shocked) given over 15 minutes.
     -  Repeat as needed to restore circulation
     -  At 40 ml/kg then discuss with a senior for consideration for inotropes 
 -  Insulin infusion at 0.1 units/kg/hour 1 hour after starting IV fluids


Fluids:

- Further fluids, following initial boluses should contain 40 mmol/l potassium chloride to protect against hypokalaemia. 
- Total fluid required = deficit + maintenance
- Hourly rate = [(Deficit - initial bolus) / 48 hours ] + maintenance per hour 
- Deficit 
        - A 5% fluid deficit is assumed for children with mild or moderate DKA
        - A 10% fluid deficit is assumed for children with severe DKA
        - Deficit should be replaced over 48 hours alongside maintenance fluids 
- Maintenance 
        - Calculated by Holliday-Segar formula: 100 ml/kg/day for the first 10 kg, 50 ml/kg/day for the next 10 kg, and 20 ml/kg/day for each additional kg over 20 kgs. 
 
Important points to consider: 

- Monitoring should include hourly blood glucose and ketones, neurological observations and fluid balance. 
- Investigations should be done to determine the cause of the DKA. 
- Many patients will require HDU-level care. 
- Intravenous insulin infusion should not be stopped until 1 hour after subcutaneous insulin has been given.
- Long-acting insulin should continue to be given.


# Resolving DKA

IVF can be stopped once ketosis is resolving and oral fluids are tolerated without nausea or vomiting. 

Subcutaneous insulin can be started once ketosis is resolving and should be started at least 30 minutes before stopping intravenous insulin. 

Discharge can be considered once a child is eating and drinking, and stabilised on their subcutaneous insulin regime. 
 

# Complications


Important complications to monitor for include:

- Cerebral oedema:
    - Can occur several hours after the onset of DKA due to rapid correction of dehydration with IV fluids. 
    - Due to the potential risk, fluid deficit correction is recommended to be performed slowly, over 48 hours. 
    - Though rare, this complication is fatal in 1 in 4 children. 
    - Risk factors include younger age and longer duration of symptoms. 
    - Management includes hypertonic (2.7%) sodium chloride and restriction of IV fluids. 
- Hypokalaemia 
- Aspiration pneumonia 
- Venous thromboembolism 
    - Thromboembolic prophylaxis is not recommended in children < 16 years 
- Inadequate resuscitation 
- Hypoglycaemia
        - Blood glucose levels can fall rapidly with intravenous insulin, and if blood glucose falls below 14 mmol/L, IV fluids should include glucose. 

# Prognosis

Early detection and treatment results in good outcomes for patients with DKA, with many children discharged within a few days of DKA.  Poorer outcomes are associated with delays in treatment and the development of cerebral oedema. 


# NICE Guidelines

[BNFC Treatment Summaries: Diabetic hyperglycaemic emergencies](https://bnfc.nice.org.uk/treatment-summaries/diabetic-hyperglycaemic-emergencies/) 
 

# References
 
[BSPED Guidelines for Management of DKA in Children](https://www.bsped.org.uk/media/1959/dka-guidelines.pdf)
 
[Patient Info: Childhood ketoacidosis](https://patient.info/doctor/childhood-ketoacidosis#ref-2)
670
2646
Emergency Management of Diabetic Ketoacidosis
Topic
29
Paediatrics
6428
In diabetic ketoacidosis (DKA), an initial resuscitation fluid bolus of 10-20 ml/kg of 0.9% normal saline is recommended to restore intravascular volume and improve circulation.
A 5-year-old boy presents to Accident & Emergency with a one-day history of abdominal pain and vomiting. He weighs 40 kg and has no past medical history of note.


Observations on triage: Temperature 36.5°C, pulse 90, blood pressure 100/70, SpO2 98% on room air.


On examination, his abdomen is soft with mild generalised tenderness, and bowel sounds are present.


Initial investigations are as follows:

||||
|---------------------------|:-------:|--------------------|
|Sodium|124 mmol/L|135 - 145|
|Potassium|5.5  mmol/L|3.5 - 5.3|
|Chloride|85 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|Non-fasting Glucose|30.5 mmol/L|< 6.1|
|Ketones (Serum)|4 mmol/L|< 0.6|


Arterial blood gas:

||||
|--------------|:-------:|------------------|
|pH|7.15|7.35 - 7.45|
|PaO₂|12 kPa|11 - 15|
|PaCO₂|4 kPa|4.6 - 6.4|
|Bicarbonate|14 mmol/L|22 - 30|


Which is the next most appropriate prescription to administer?
a