Children with Diabetic Ketoacidosis

Signs and Symptoms

• Vomiting, polyuria, dehydration, ketonuria and acidosis. The blood sugar will be high >15mmol/l

Treatment

• Address airway and breathing
• IV fluids are the most important resuscitation measure
• Give Normal Saline or Ringers Lactate
• Give 10mls/kg bolus and repeat to a maximum of 30mls/kg to correct shock if present
• Ongoing fluid requirement = (Maintenance) plus (Deficit) minus (shock bolus)
• CORRECT OVER 48HRS TO AVOID CEREBRAL OEDEMA

Child is usually approx. 7.5 to 10 % dehydrated. Deficit is calculated as % body weight loss.

Maintenance is calculated as per shown below

Maintenance requirements are as follows:

• First 10 kg body weight 100mls /kg /day
• Next 10 kg body weight 50mls/kg/day
• Each kg thereafter 20mls/kg /day.

For example:

• Comatose child weighing 20kg on admission in shock in DKA X 10ml/kg bolus needed to correct shock = 2 X 200 = 400mls
• Maintenance is 1.5L/ day (1000mls +500mls)
• Deficit= 20kg X 7.5% = 1.5L (one litre weighs1kg)
• Requirement over 48 hours
• Maintenance (1.5 +1.5L) +deficit (1.5L) minus bolus (400) 4.1L +/48hours = 85ml/hr
• Add Potassium Chloride to IV fluids when patient urinates, and peripheral circulation has improved.
• Change to oral K+ supplements when patient is able to feed.
• ECG monitoring if potassium is <2.8 or >6mmol/L

Give Insulin

• Should be short acting, soluble
• Start insulin one hour after starting IV fluids
• start with small subcut dose of 0.1u/kg. Recheck blood glucose after an hour.
• If glucose is unchanged or increased, repeat subcut dose of 0.1u/kg. Repeat hourly until blood glucose starts falling.

Sliding Scale:

• Blood glucose (mmol/L)
• >20kg: 0.5u/kg
• 15-19.9kg:0.4u/kg
• 10-14.9kg:0.3u/kg
• 5 - 9.9kg: 0.2u/kg
• 2-4.9kg: 0.1u/kg only if on a glucose drip
• <2: omit Insulin and give Dextrose or food

Ongoing Management:

• Change IV fluid to 1/2 strength Darrow’s or 5 % Dextrose if blood glucose <15mmol/L
• IV fluids must be continued until child is drinking well, tolerating oral feeds and has ketone free urine
• Monitor level of consciousness. Deteriorating neurological state may indicate cerebral oedema. Ensure airway is protected
• Consider NGT on free drainage if child is unconscious.
• Check each urine passed for glucose and ketones as a guide to recovery
• Maintenance Insulin requirements
• Once child is drinking and eating
• Calculate total daily dose of insulin once the child is stable. This is usually 0.5 to 1u/kg/day but should be based on the Insulin requirement of the previous 24hours.
• If only short acting Insulin is available:
• Continue TDS regime prior to meals according to requirement
• If long acting is available:
• BD regime, 2/3 of the total dose should be given before breakfast and 1/3 before dinner
• Proportion for long acting and short acting should be about 2:1 to 3:1
• Educate patient and family on diet:
• Importance of regular meals
• Avoid refined sugars e.g., SOBO, bananas, cakes and biscuits
• Encourage complex carbohydrates e.g. cereals and a high fibre diet
• Educate patient and family on Insulin:
• Keep in a cool place e.g., clay pot if no refrigerator
• Rotation of injection sites
• How to give injections