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Diabetic ketoacidosis (DKA) is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.
DKA is often insidious in onset with slow progression of the illness.
Definition of DKA by biochemical criteria includes the following:
In type 2 diabetes mellitus, hyperglycemic hyperosmolar state (HHS) can occur and is defined by the following:
Plasma glucose concentration >600 mg/dL
Arterial pH >7.30
Serum bicarbonate >15 mmol/L
Small ketonuria and absent or mild ketonemia
Serum osmolarity ≥320 mOsm/kg
Stupor or coma
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Treatment of DKA consists of rapid assessment, replacement of the patient's fluid and electrolyte deficit, and reversal of the central pathophysiologic process by the administration of insulin.
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The initial fluid resuscitation is with normal saline at a dose of 20 mL/kg over 1 to 2 hours. After the initial bolus, the patient's cardiovascular status is reevaluated and a second bolus may be administered.
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An initial bolus of insulin is unnecessary and can increase the risk for cerebral edema. The insulin infusion dose is 0.1 U/kg/h and this should continue till resolution of DKA (pH >7.3, bicarbonate >15 mmol/L).
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Potassium replacement therapy is started once normal or low serum potassium is ensured and urine output is established. The usual dose of potassium is twice-daily maintenance or 3 to 4 mEq/kg per 24 hours provided as 40 mEq/L in the IV fluids, with half as potassium chloride or potassium acetate and half as potassium phosphate.
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Cerebral edema occurs in 0.5% to 0.9% of DKA patients and the mortality rate is 21% to 24%. The predisposing factors are younger age, new onset diabetes, and longer duration of symptoms.
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Newborns and young infants with hypoglycemia may be asymptomatic or may manifest nonspecific symptoms. Older children exhibit more classic symptoms of hypoglycemia, including sweating, tachycardia, tremor, anxiety, tachypnea, and weakness.
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Treatment of Hypoglycemia
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In newborns, give 10% dextrose 2 mL/kg (0.2 g/kg) as a bolus, followed by infusion at 6 to 9 mg/kg/min
In children, give 10% dextrose at 5 mL/kg (0.5 g/kg) as a bolus, followed by continuous infusion at 6 to 9 mg/kg/min
If an IV line is not possible, then give glucagon 0.03 mg/kg (maximum dose 1 mg) subcutaneously
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Admission of the hypoglycemic patient is indicated when there is no obvious cause, toxic ingestion as with oral hypoglycemic agents is suspected, administration of long-acting insulin was the cause, or if there are persistent neurological deficits.
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DKA is a complex endocrine condition caused by an absolute or relative lack of insulin. It is characterized by hyperglycemia, dehydration, ketosis, and metabolic acidosis.
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