Diabetic ketoacidosis in Child
Relative insulin deficiency prevents the normal uptake of glucose from the blood into cells, resulting in hyperglycemia and an osmotic diuresis due to glucosuria causing serum hyperosmolarity and dehydration. Without glucose as a fuel source, cells break down triglycerides and other fats, creating free fatty acids (FFA) and ketone bodies, which results in acidosis. Patients may present with varying degrees of severity, ranging from mild acidosis to life-threating acidosis with hyperosmolarity that may result in coma or death.
DKA may be seen at the initial presentation (30%) of type 1 DM or in a previously diagnosed patient with DM who has a concurrent infectious illness or very poor DM control / medication compliance. Presenting symptoms may include weight loss, polyuria, polydipsia, abdominal pain, nausea, vomiting, dehydration, lethargy, and tachypnea. Symptoms of the underlying illness that triggered the DKA episode may also be present. In more severe cases, mental status changes, seizures, and Kussmaul respirations may be seen. The patient's breath may have a fruity smell due to respiratory acetone elimination.
Urinalysis will show glucosuria with high ketones. An anion gap metabolic acidosis will be present with hyperglycemia and increased blood osmolality. Hypokalemia (less than 3.5 mEq/L) may also be present and may worsen with treatment. Treatment must be expeditious but careful to avoid the complication of cerebral edema.
Initial acute management consists of general resuscitation measures to address airway, breathing, and circulatory (ABC) issues to stabilize the patient. A comatose patient may require intubation. Two large-bore intravenous (IV) lines should be obtained. An insulin drip with short-acting insulin is initiated with careful correction of fluid and electrolyte deficits. Laboratory tests and clinical status need to be carefully monitored on a frequent basis to avoid complications.
E13.10 – Other specified diabetes mellitus with ketoacidosis without coma
420422005 – Ketoacidosis in diabetes mellitus
- Starvation ketosis
- Ethanol-induced metabolic acidosis
- Uremic acidosis
- Alcohol intoxication
- Toxic encephalopathy
- Salicylate toxicity
- Hyperosmolar coma
- Viral gastroenteritis with dehydration
Careful monitoring is required during treatment to prevent rapid changes in osmolality or electrolytes that could lead to cerebral edema or cardiac instability and death.