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Diabetic ketoacidosis
Complications
Cerebral edema
- Approximately 0.4–1% of children with DKA develop cerebral edema with a high mortality/morbidity
- Cerebral edema most commonly occurs in the first 24 h after starting rehydration when the general condition of the child might seem to be improving. Vigilant observations throughout the 24 h must not diminish
- In many cases warning signs/symptoms occur which should prompt the emergency administration of mannitol
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Warning signs/symptoms of cerebral edema
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Headache and slowing of heart rate
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Change in neurological status (restlessness, irritability, increased
drowsiness, incontinence) or specific neurological signs (e.g.
cranial nerve palsies)
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Rising blood pressure, decreased O2 saturation
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- More dramatic changes such as convulsions, papilledema and respiratory arrest are late signs associated with extremely poor prognosis
Action
- Exclude hypoglycemia
- If warning signs occur at any time of day or night, give immediate IV mannitol 1 g/kg over 20 min (i.e. 5 ml/kg 20% solution)
- Halve rehydration infusion rate until situation is improved
- Nurse with child’s head elevated
- Move to intensive care unit as soon as possible
- Alert anesthetic and senior pediatric staff (if assisted ventilation is required maintain PCO2 above 3.5 kPa)
- Consider continuation of mannitol infusion 0.25 g/kg per h to prevent rebound increase in intracranial pressure (or repeat bolus doses every 4–6 h)
- Cranial imaging should only be considered after child has been stabilized. Intracranial events other than edema may occur, e.g. hemorrhage, thrombosis, infarction
Mannitol should be immediately available during the treatment of DKA
Hypoglycemia and hypokalemia
Avoid by careful monitoring and adjustment of infusion rates
Aspiration pneumonia
Avoid by nasogastric tube in vomiting child with impaired consciousness
Other associations with DKA
These require specific management, e.g. continuing abdominal pain (due to liver swelling/gastritis/bladder retention — but beware appendicitis), pneumothorax ± pneumomediastinum, interstitial pulmonary edema, unusual infections (e.g. TB, fungal infections), hyperosmolar hyperglycemic non-ketotic coma, ketosis in type 2 diabetes
Transition to SC insulin injections
- Oral fluids should be introduced only when substantial clinical improvement has occurred (mild acidosis/ketosis may still be present)
- When oral fluids are tolerated, IV fluid should be reduced
- Insulin infusion may be continued with adjustments to cover oral carbohydrate intake
or
- Insulin by SC injection may be started when oral intake is tolerated
- The dose and type of SC insulin given will depend on local circumstances
- To prevent rebound hyperglycemia do not stop the IV insulin infusion until 60 min after the first SC injection of short or rapid-acting insulin
Algorithm for the management of DKA
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