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I get insulin but dont you start with saline infusion first?
61196
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oh wait the Q asked high blood glucose levels
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Vitals 'R' Us
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Vitals 'R' Us
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was so confused because you can't write "per hour" anywhere
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Vaccine Complement
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)
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Emergency Management of Diabetic Ketoacidosis
Topic
9
Internal Medicine
# Drug choice feedback

Any rapid-acting or short-acting insulin is appropriate for the treatment of diabetic ketoacidosis. Common ones include NovoRapid/Humalog and Actrapid/Humilin S respectively. Prescribing insulin by brand name is acceptable; an exception is made as each brand of insulin may have different formulations even if it belongs to the same class as another.

# Dose/Route/Frequency/Duration feedback

The dose of insulin to be administered is 0.1units/kg/hour IV. Since the patient's weight is 75kg, the dose is 7.5 units per hour IV. S/C administration is not appropriate for the treatment of DKA.
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PrescriptionAnswer
PrescribeAnswerData
7.5 units
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insulin lispro 100 units/mL (Humalog®) injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
7.5 units
PrescribeAnswerData
insulin soluble human 100 units/mL (Actrapid®) injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
7.5 units
PrescribeAnswerData
insulin soluble human 100 units/mL (Humulin S®) injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
7.5 units
PrescribeAnswerData
insulin aspart 100 units/mL (NovoRapid®) injection
PrescribeAnswerData
Continuous
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
7.5 units
PrescribeAnswerData
insulin aspart 100 units/mL (NovoRapid®) injection
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Continuous
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once only (STAT)
PrescribeAnswerData
intravenous (IV)
Case Presentation: A 27-year-old gentleman is brought to the Emergency Department with abdominal pain, vomiting, polydipsia and polyuria. Intravenous fluids have already been commenced.
 

 

## PH
 

None
 

## DH
 

None
 

## On examination
 

Drowsy but able to answer in full sentences. Sick bowl present on side table. Rapid breathing. Dry mucous membranes, peripheries cool, CRT 3s.
 

Temperature 36.4°C, HR 105, RR 31, BP 95/78, O<sub>2</sub> 98% RA, GCS 14, Weight 75kg
 

## Investigations
 

|      |    |         |
| -------------- | :-------: | ------------------ |
| pH               |     7.2    | 7.35 - 7.45        |
| PaO₂             | 12 kPa       | 11 - 15          |
| PaCO₂            | 3.2 kPa      | 4.6 - 6.4         |
| Bicarbonate      | 12 mmol/L        | 22 - 30      |
| Sodium                      | 125 mmol/L          | 135 - 145     |
| Potassium                   | 4.7 mmol/L          | 3.5 - 5.3     |
| Non-fasting Glucose         | 28 mmol/L          | < 6.1               |
| Ketones (Serum)             | 4.5 mmol/L          | < 0.6               |


# Prescribing Request
 

Write a prescription for one drug that is most appropriate to specifically treat the high blood glucose levels.