However, much of the discussion in dka management throughout the years has centered around the initial hours of therapy, with a focus on sodium, water, bg decrease, and their effect on rapid osmolar shifts. Management of diabetic ketoacidosis by michael agus, md for openpediatrics. Morbidity and mortality of dka in children mortality has been constant at 0. The optimal fluid management for diabetic ketoacidosis dka is uncertain. For new onset diabetes in a pediatric patient not in dka see criteria. With the new advances of therapy, dka mortality decreased to in prevalence. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to. Timing is crutial when a pediatric patient presents themselves with the symptoms for dka. Management of diabetic ketoacidosis in children and. Pediatric diabetic ketoacidosis dka treatment guide.
We performed a retrospective study to determine the effects of. Diabetic ketoacidosis, pediatric emergency and inpatient v 1. Diabetic ketoacidosis dka is an endocrine emergency occurring in new onset and established type 1 diabetic patients. Diabetic ketoacidosis dka critical care guideline two bag system. Learn about the best practices in managing and monitoring patients with diabetic ketoacidosis.
The center is a consistent incubator for novel ideas and discoveries in the immunology, genetics, and cell biology of diabetes that have developed into diagnostic assays now standard in diabetes research. Nov 20, 2018 the goals of dka treatment are to normalize volume status, hyperglycemia, electrolytes, and ketoacidosis. The epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric onset diabetes are different from adult diabetes. Potential complications include cerebral edema, hypokalemia, hypoglycemia, and relapse. With significant ketosis, patients may have a fruity breath. If the rate of blood glucose fall exceeds 5 mmoll per hour, or falls to around 14 mmoll, add dextrose 510% equivalent to the iv fluids running see fluids above. In individuals who have no previous diagnosis of diabetes mellitus, a preceding history of polyuria, polydipsia, and weight loss usually can be elicited.
Management of diabetic ketoacidosis openpediatrics. Management of diabetic ketoacidosis in picu article pdf available in the indian journal of pediatrics 746. Management should be conducted in a center experienced in the treatment of dka in children and adolescents and where vital signs, neurological status and. It is a wellestablished fact that resolution of acidosis and not blood glucose bg reduction determines the end point of dka therapy. The approach to management will vary depending on the specific problem for the individual patient eg, recurrent diabetic ketoacidosis dka, recurrent severe hypoglycemia, or both cerebral injury cerebral edema in children with diabetic ketoacidosis view in chinese. In the last decade, however, there has been a change in the way patients with dka present clinically and in addition there has been rapid development of nearpatient testing. Diabetic ketoacidosis dka in children and adolescents has a mortality rate of 1% to 2%. Due to its increasing incidence and economic impact related to the treatment and associated morbidity, effective management and prevention is key. Diabetic ketoacidosis dka is an emergency for people with diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. Diabetic ketoacidosis results from untreated absolute or relative deficiency of insulin in type 1 or type 2 diabetes mellitus, respectively. The administration of iv fluids should be done very judiciously in the pediatric population. Updates in the management of diabetic ketoacidosis the. These guidelines for the management of dka in children and young people under the age of 18 years are based on the nice guideline for type 1 and type 2 diabetes in children and young people published.
Management of diabetic ketoacidosis dka in pediatrics. Management of pediatric dka there are a number of important differences between the management of dka in pediatrics compared to adult patients. The management of diabetic ketoacidosis in adults our. Diabetic ketoacidosis, pediatric emergency and inpatient. Treatment protocols for pediatric diabetic ketoacidosis dka vary considerably among centers in the usa and worldwide. Pediatric dka management in the era of standardization.
The fundamental pathophysiology of this potentially lifethreatening complication is the same as in adults. Acute management of pediatric diabetic ketoacidosis. However, the child differs from the adult in a number of characteristics. Diabetic ketoacidosis dka is a preventable lifethreatening complication of type 1 diabetes. The mortality rate in patients with diabetic ketoacidosis dka is in experienced centers, whereas the mortality rate of patients with hyperosmolar hyperglycemic state hhs still remains high. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury. Therefore, the best treatment of dka is prevention through early recognition and diagnosis of diabetes in a child who has polydipsia and polyuria and through careful attention to the treatment of children who have known diabetes, particularly during illnesses. Nurse practitioners are well positioned to promote patient education, self management, and individualized patient care. Joint british diabetes societies inpatient care group. Dka frequency at the time of diagnosis of pediatric diabetes is 10%70%, varying with the availability of healthcare and the incidence of type 1 diabetes t1d in. Ada1,chi management and treatment of pediatric type 1 diabetes care process model february 2017. Diabetic ketoacidosis dka severe dka is a grave illness and is the commonest cause of diabetesrelated deaths in children and adolescentsmost deaths in dka occur in young people as a result of cerebral oedematreatment is distinctly different from adults because of the threat ofcerebral oedemadeaths should be avoidable bya reducing the. Participants were asked management questions regarding a hypothetical 10yearold, 40kg child presenting with newonset. Status epilepticus on the pediatric ward by nadeen abujaber for.
Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. Management and treatment of pediatric type 1 diabetes. Dka frequency at the time of diagnosis of pediatric diabetes is 10%70%, varying with the availability of healthcare and the incidence of type 1. One of the most severe complications of diabetes, diabetic ketoacidosis dka, results from insulin deficiency and is a medical emergency that is frequently encountered in the emergency department. This has impacted the quality of care provided to pediatric patients in ceds. Participants were asked management questions regarding a hypothetical 10yearold, 40kg child presenting with newonset diabetes, 10% dehydration, and vomiting. Clinicians should understand the appropriate management and risks associated with treatment of children with diabetic ketoacidosis.
Diabetic ketoacidosis dka is a complex metabolic state of hyperglycemia, ketosis, and acidosis. Management of diabetic ketoacidosis dka in pediatrics physician direct connect line 614 7222052 1866 7222052. Fluid therapy for pediatric patients with diabetic. Bhyperglycemic hyperosmolar state hhs should be suspected when there is significant. Diabetic ketoacidosis dka critical care guideline two. The prognosis of dka is worse in the extremes of age, with a mortality rates of 510%. Recurrent dka without a preceding febrile or vomiting illness is almost always the result of psychosocial problems and failure to take insulin e. Kelly bergmann and colleagues present a quality improvement qi initiative 10. Our 2019 revision aligns closely with the dka protocol developed by trekk translating emergency knowledge for kids, which is designed for the initial management of pediatric dka in most canadian emergency departments, as well as with the dka algorithm developed by the canadian pediatric endocrine group, which is designed for ongoing inpatient. One of the goals of medical management of dka is to avoid excessive decreases in serum glucose 100 mgdl per hour that could increase the potential risk of cerebral edema due to rapid changes in serum osmolarity 2. Pediatric dka was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at trekk translating emergency knowledge for kids one of em cases partners whos mission is to improve the care of children in nonpediatric emergency departments across the country.
Feb 23, 2016 management of diabetic ketoacidosis by michael agus, md for openpediatrics. Diabetic ketoacidosis dka, a lifethreatening complication of type 1 diabetes, is preventable but errors in the way it is managed are common and and associated with significant morbidity and mortality. Can children with mild diabetic ketoacidosis be managed. Understand the basic clinical presentation, diagnostic tests, and management of dka. This cpm is based on guidelines from the american diabetes association ada, particularly the 2014 position statement type 1 diabetes through the life span, as well as the opinion of local clinical experts in pediatric diabetes. We sought to create and implement recommendations from an evidencebased pathway for hospital management of pediatric diabetic ketoacidosis dka and to sustain improvement. Understand the etiology of diabetic ketoacidosis dka. Diabetic ketoacidosis dka is the most common cause of premature mortality in children with type 1 diabetes. C 29, 32 bicarbonate therapy has not been shown to.
Dka pathophysiology treatment management nclex duration. Dka also can occur in children with type 2 diabetes. Patients who have dka generally present with nausea and vomiting. Weve helped produce the management of diabetic ketoacidosis in adults, pdf, 4mb published by the joint british diabetes societies inpatient car. Blood glucose bg 200 mgdl acidosis bicarbonate dka also can occur in children with type 2 diabetes. Treatment of dka involves careful fluid resuscitation, insulin administration, electrolyte replacement, and close monitoring for signs of cerebral. The adage a child is not a miniature adult is most appropriate when considering diabetic ketoacidosis dka. The majority of pediatric patients with diabetic ketoacidosis dka present to community emergency departments ceds that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. Diabetic ketoacidosis dka is biochemically defined as a venous ph 200 mgdl 11 mmoll together with ketonemia, glucosuria, and ketonuria.
Our goal was to describe our longterm experience in the management of. Patients identified with diabetic ketoacidosis during their hospital stay background definitions diabetic ketoacidosis dka is a lifethreatening condition. Diabetic ketoacidosis dka critical care guideline two bag. Fluids form a crucial component of dka therapy, goals being the restoration of intravascular, interstitial and intracellular compartments. Recommendations concerning fluid management have been modified to reflect recent findings from a randomized controlled clinical trial showing no difference in cerebral injury in patients rehydrated at different rates with either 0.
These guidelines for the management of dka in children and young people under. Nurse practitioners are well positioned to promote patient education, selfmanagement, and individualized patient care. Pdf diabetic ketoacidosis in children researchgate. See classification of diabetes mellitus and genetic diabetic syndromes. Diabetic ketoacidosis dka childrens hospital colorado.
Management of diabetic ketoacidosis by michael agus, md. Those with severe dka have a much higher mortality and risk of complications. Diabetic ketoacidosis diabetes type i management summary. The criteria for hyperglycemic hyperosmolar state hhs include. In their larger and welldesigned study to characterize the risk factors for cerebral edema in the management of dka, glaser et al did not identify either rates of fluid or insulin administration as risk factors.
This article outlines updates in the clinical management of. Pdf the management of diabetic ketoacidosis in children. Pediatric diabetic ketoacidosis emergency department care. The management of diabetic ketoacidosis in children ncbi. The management of diabetes in children and adolescents cannot simply be derived from care routinely provided to adults with diabetes.
Guidelines for the management of patients with dka and hhs. The management of diabetic ketoacidosis in children. These disorders can occur in both type 1 and type 2 diabetes. This educational tool is a powerpoint presentation that allows providers to quickly access guidelines for acute management of pediatric diabetic ketoacidosis dka. To address these issues the joint british diabetes societies jbds, supported by nhs diabetes, has produced this revision of the 2010 guidance developed by a multidisciplinary group of practicing specialists with considerable experience in this area. C 22 subcutaneous insulin can be used for treatment of uncomplicated dka. Insulin therapy for the management of diabetic ketoacidosis. Cerebral edema is a life threatening complication of dka which occurs in up to 3% of dka episodes. Children with diabetic ketoacidosis dka present differently and require different treatment than adults with dka, according to newly published guidelines from the american diabetes association ada.
Nov 07, 20 introduction dka is a serious acute complications of diabetes mellitus. Dka is the most common cause of death in children who have type 1 diabetes. Therefore, the best treatment of dka is prevention through early recognition and diagnosis of diabetes in a child who has polydipsia and polyuria and through. Acidosis bicarbonate diabetic ketoacidosis dka is an emergency for people with diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. May 21, 2018 diabetic ketoacidosis dka is a complex metabolic state of hyperglycemia, ketosis, and acidosis.
Diabetic ketoacidosis dka is the leading cause of morbidity and mortality in children with type 1 diabetes, with a case fatality rate ranging from 0. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Management of diabetic ketoacidosis in children and adolescents. Dka without a preceding febrile illness or gastroenteritis in a patient with known diabetes is almost always the result of psychosocial problems and failure to appropriately administer insulin. Do not administer bicarbonate in the routine management of dka. Improving management of diabetic ketoacidosis in children. See diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults. Improving pediatric diabetic ketoacidosis management in. Children with dka are best managed at a facility where written guidelines are available, with nursing and medical staff experienced in pediatric dka management, preferably with pediatric. Significant risk of death andor morbidity especially with delayed treatment. Diagnosis and management of dka hemogol bn i a1c management of an episode of dka is not complete until an attempt has been made to identify and treat the cause. In an effort to simplify dka therapy, we revised the treatment protocol in our institution to use a simpler method of calculating fluid needs, use fluids with higher sodium concentration, and allow glucose concentration to be adjusted easily.
Currently, there are no existing data from prospective clinical trials to determine the optimal fluid treatment protocol for pediatric dka. A mail survey of 1,000 randomly selected physicians, including various pediatric specialties and general emergency physicians, was completed to study the variation among specialties in the management of pediatric dka. The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of these disorders are discussed separately. Management of diabetic ketoacidosis article pdf available in the indian journal of pediatrics 785. These images are a random sampling from a bing search on the term diabetic ketoacidosis management in children. Almost 1 in 100 children with dka will develop cerebral edema, which has a mortality rate of 2124%. Treatment and management methods used for dka in adult patients may increase the risk of cerebral edema in pediatric patients. Jun 30, 2014 diabetic ketoacidosis dka is a rare yet potentially fatal hyperglycemic crisis that can occur in patients with both type 1 and 2 diabetes mellitus. Diabetic ketoacidosis american academy of pediatrics. Diabetic ketoacidosis dka is the leading cause of mortality in childhood diabetes. The proper management of dka requires intense monitoring and clear understanding of pathophysiology related to it. Diabetic ketoacidosis in a patient in whom diabetes is newly diagnosed can be prevented only if the general public and primary care physicians know the symptoms and if physicians are alert, particularly with regard to young children, to the possibility of diabetic ketoacidosis developing. While adults require large volumes of intravenous fluids, large volumes of fluid are harmful in pediatric dka. Apr 25, 2014 diabetic ketoacidosis, together with the major complication of cerebral edema, is the most important cause of mortality and severe morbidity in pediatric cases of diabetes, particularly at the time of first diagnosis.
After completing this article, readers should be able to. Cerebral edema in diabetic ketoacidosis by michael agus. Management of an episode of dka is not complete until an attempt has been made to identify and treat the cause. Pediatric diabetic ketoacidosis guidelines mainehealth. Diabetic ketoacidosis dka critical care guideline two bag system inclusion criteria definition of dka. Scope children with known or newly diagnosed diabetes mellitus.
Ispad 2009, mcgeoch 2007, savage 2006, bsped 2004, kitabchi 2009. Management of diabetic ketoacidosis by michael agus, md for. Dka onset and recurrence can largely be prevented through patient education. Bsped recommended guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis 2015. Pharmacists in community or ambulatorycare settings can assist in preventing dka, while inpatient pharmacists play a role in management of dka.
Acidosis bicarbonate management of diabetic ketoacidosis in children, including an algorithm for intravenous fluid administration. Diabetic ketoacidosis including fluid calculation sheet. Sep 11, 2017 diabetic ketoacidosis diabetes type i management summary armando hasudungan. We hypothesized that development and utilization of standard work for inpatient care of dka would lead to reduction in hypokalemia and improvement in outcome measures.