Chapter 77: Diabetes Mellitus and Hypoglycemia

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:

• Hyperglycemia: Blood glucose >200 mg/dL

• Venous pH <7.3 or bicarbonate <15 mmol/L

• Ketonemia and ketonuria

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.

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/L

• Stupor or coma

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.

Treatment of hypoglycemia

• 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. Alternatively, follow the “50 rule” in which the mL/kg multiplied by the dextrose % equals 50. For example, 1 mL/kg of D50, 2 mL/kg of D25, 5 mL/kg of D10, etc.

• If an intravenous (IV) line is not possible, then give glucagon 0.03 mg/kg (maximum dose 1 mg) subcutaneously.

• 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.