QuestionSBA
QuestionChoice
This would indicate hypoxaemia, commonly seen respiratory failure in conditions such as chronic obstructive pulmonary disease (COPD). Hypoxaemia is not a common finding in DKA
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b
A PaO2 of 7.1kPa
QuestionChoice
Reduced conscious level in a young patient with high peripheral blood sugars should make you think of the first presentation of type 1 diabetes. This vignette is a classic example of a patient in diabetic ketoacidosis where she cannot utilise glucose for her energy needs and has therefore gone into a ketotic state. You would therefore expect her blood gas to show a metabolic acidosis. She has a high respiratory rate as she is trying to use hyperventilation to compensate for her acidosis by expelling her carbon dioxide
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a
A pH of 7.20
QuestionChoice
This blood gas demonstrates an alkalosis which may be caused by loss of electrolytes (commonly potassium) as seen in severe vomiting and diarrhoea. DKA cause an acidosis, demonstrated by a low pH
32641
d
A pH of 7.49
QuestionChoice
This patient has DKA, and you would therefore expect the blood gas to show hyperglycaemia. Patients can rarely have euglycaemic diabetic ketoacidosis but this is often associated with certain medications such as SGLT2 inhibitors
32642
e
A glucose of 10.4mmol/L
QuestionChoice
This blood gas shows a hypercapnoea. This is common in acute respiratory presentations such as an acute asthma attack. In DKA the carbon dioxide tends to be low due to compensatory hyperventilation for the acidosis
32640
c
A PaCO2 5.4kPa
QuestionComment
I thought increased respiratory rate points towards hyperventilation --> respiratory alkalosis and hence a high pH (7.49)?
22699
QuestionComment
I did the same thing 
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User
subscriber
JAK Suture
QuestionComment
The raised RR is to compensate for the metabolic acidosis but it will only be partial.
26347
User
subscriber
Rhinoplasty Contusion
User
subscriber
Rhinoplasty Recessive
QuestionComment
I need to go back to primary school at this rate
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Serpiginous Defibrillator
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
29
Paediatrics
6528
In diabetic ketoacidosis (DKA), an arterial blood gas (ABG) typically shows metabolic acidosis with a low pH (usually <7.35), decreased bicarbonate (HCO3-) levels, and an anion gap that is often elevated due to the accumulation of ketoacids.
A 14-year-old female is brought into the Emergency Department by her parents due to a reduced consciousness level. On examination, she is thin and appears dehydrated and drowsy. Her observations are as follows:


 - Temperature 36.5°C
 - Blood pressure 110/65 mmHg
 - Heart rate 120 bpm
 - Respiratory rate 32 bpm
 - Oxygen saturations 99% (on air)
 - Peripheral blood glucose 25mmol/L (normal <6.1 mmol/L)


Which of the following findings are you most likely to find on an arterial blood gas?
a