D.M.

1- A mother calls you about her 8 years old son , known case of DM-1 fell comatose . she is not
sure if he took the night & morning dose of insulin. You will advice her to :
a- bring the child immediately to the ER
b- call an ambulance
c- give him IV glucagons
d- give him IV insulin
e- give him drink contains sugar
Diabetic ketoacidosis can develop very rapidly in a patient with established diabetes, particularly
when insulin therapy has been forgotten, deliberately omitted, or disrupted, as with children on
continuous subcutaneous insulin infusions (CSII) or using the newer analogue insulins. Under these
circumstances, diabetic ketoacidosis may present with relatively normal blood glucose levels (ie,
250 mg/dL, 15 mmol/L) or less.
Symptoms of hyperglycemia
o
Increased volume and frequency of urination (polyuria)
o
Polydipsia: Thirst is often extreme, with children waking at night to consume large
quantities of any available drinks.
o
Nocturia and secondary enuresis in a previously continent child
o
Weight loss, which may be dramatic due to breakdown of protein and fat stores
o
Muscle pains and cramps
Symptoms of acidosis and dehydration
o
Abdominal pain that may be severe enough to present as a surgical emergency. For
children with a failure of CSII, this may be the first presenting sign, along with
vomiting.
o
Shortness of breath that may be mistaken for primary respiratory distress
o
Confusion and coma in the absence of recognized head injury21
Other symptoms
o
Vomiting
o
Signs of intercurrent infection (eg, urinary tract infection, respiratory tract infection)
o
Weakness and nonspecific malaise that may precede other symptoms of
hyperglycemia
Physical
Dehydration may be observed.
o The degree of dehydration is often reported to be approximately 5-10% but easily
can be overestimated. Clinical signs, such as dry mouth, sunken eyes, and decreased
skin turgor, are present from about 3% dehydration.
o When the dehydration is estimated from comparing current against previous known
weights, allow for the loss of protein, fat, and glycogen stores, which otherwise
would exaggerate fluid losses. Table 1. Clinical Assessment of Dehydration
Moderate
Severe 10% and
Mild <3%
3-10%
Shock 15%
Appearance
Thirsty, alert Thirsty lethargic Drowsy, cold
Tissue turgor

Normal

Absent

Absent

Mucous membranes Moist

Dry

Very dry

Blood pressure

Normal

Normal or low

Low for age

Pulse

Normal

Rapid

Rapid and weak

Eyes

Normal

Sunken

Grossly sunken

Anterior fontanelle Normal

Sunken
Grossly sunken
Blood pressure is usually normal until terminal stages of illness.
Tachycardia may be present.
Capillary refill is initially maintained, but a combination of increasing acidosis and
dehydration cause poor tissue perfusion.
Kussmaul breathing or deep sighing respiration is a mark of acidosis. These symptoms may
be mistaken for status asthmaticus, pneumonia, and even hysterical hyperventilation.
Patient may have a smell of ketones on the breath. (Many people cannot detect this smell.)
Impaired consciousness occurs in approximately 20% of patients.
Coma may be present in 10% of patients.
Abdominal tenderness may occur.
o Tenderness is usually nonspecific or epigastric in location.
o Bowel sounds may be reduced or absent in severe cases.
Children using only analogue insulins are also at risk of rapid-onset diabetic ketoacidosis.
Omitting an evening dose of long-acting insulin may result in insulin deficiency through the
night and typically leads to the child waking up vomiting.

2- DKA in children, all of the following are true except :

a) dont give K+ till lab results come
b) ECG monitoring is essential
c) if pH < 7.0 -* give HCO3d)NGT for semiconscious pt
e) furosemide for pt with oligouria
As always, in patients with diabetic ketoacidosis (DKA), the first principals of resuscitation apply
(ie, ABCs). Outcomes are best when children are closely monitored and changing status is promptly
addressed. Give oxygen, although this has no effect on the respiratory drive of acidosis. Diagnose
by clinical history, physical signs, and elevated blood glucose.
1. Fluid replacement: No randomized trials of fluid replacement have been conducted, and over
the years, various regimens have been proposed. Published series suggest the best outcomes
have been achieved by using isotonic sodium chloride solution or half-strength sodium chloride
solution for first resuscitation and replacement.31 Slowly correcting the fluid deficit over 24-48
hours appears safer than rapid rehydration and, thus, forms the basis for the regimen that
follows:

Calculate fluid deficit by weight loss or clinical assessment to a maximum 10% of body
weight.

In a child with severe acidosis or compromised circulation, an initial resuscitation of 10-20

mL/kg of isotonic sodium chloride solution (0.9%) can be administered over 30 minutes.

After resuscitation, slowly correct the fluid deficit over 48 hours by providing normal
maintenance fluids together with the calculated deficit.

Remember to include any fluid bolus in the total volume of fluid to be replaced.

Administer isotonic sodium chloride solution until blood glucose levels have fallen to 250300 mg/dL (ie, 12-15 mmol/L), at which time glucose-containing fluids should be
introduced (either 5% glucose with 0.9% saline or 5% glucose with 0.45% saline). Continue
maintenance with dextrose saline until the child is eating and drinking normally.

If cerebral edema develops, restrict fluid replacement to two thirds of normal maintenance
and replace the deficit over 48 or more hours.
Although strict assessment of fluid balance is important, replacement of ongoing losses is
not normally required.

2. Insulin replacement

Continuous, low-dose intravenous (IV) insulin infusion is generally accepted as the

safest and most effective method of insulin delivery for treating diabetic ketoacidosis. Lowdose IV insulin infusion is simple, provides more physiological serum levels of insulin,
allows gradual correction of hyperglycemia, and reduces the likelihood of sudden
hypoglycemia and hypokalemia.

The results of a prospective national study of diabetic ketoacidosis in the United Kingdom
suggest a greater risk of cerebral edema in patients who received insulin within the first
hour of treatment.7 In light of these results, starting insulin therapy an hour after fluid
resuscitation has commenced is prudent, especially in the newly diagnosed child.

The correct dose of insulin to infuse in the treatment of diabetic ketoacidosis is under
debate. Traditionally, 0.1 U/kg/h is given, but a lower dose of 0.05 U/kg/h is enough to
prevent gluconeogenesis and results in a slower reduction of blood glucose levels.
Regularly reviewing the response to treatment and adjusting rates accordingly is probably
better than having a single fixed rate. Adolescents with secondary DKA and insulin
resistance may need more than 0.1 U/kg/h.

Authorities commonly recommend that blood glucose levels not fall faster than 90 mg% (ie,
5 mmol/L) per hour. The infusion rate of insulin can be reduced as blood glucose levels fall
but should not drop below 0.05 U/kg/h to prevent any recurrence of ketosis. Do not
discontinue infusion until subcutaneous (SC) insulin has been given when the child has
recovered. If blood glucose falls below 120 mg% (ie, 7 mmol/L), increase the concentration
of infused glucose to prevent hypoglycemia. Ketosis clears more quickly if insulin infusions
are prolonged for 36 hours or more.

In cases of mild-to-moderate diabetic ketoacidosis where the patient is able to tolerate oral
fluids, giving repeated (hourly) SC injections of regular or fast-acting analogue insulins in a
dose of 0.1U/kg is possible. This is as effective as intravenous insulin.32,33
3. Electrolyte replacement
a. Potassium: Patients with DKA always have a total body deficit of potassium. After
initial resuscitation and if serum/plasma levels are below 5 mEq/L or a good renal
output has been maintained, add potassium to all replacement fluids. Table 2 provides
examples of infusion concentrations as mEq/L for differing degrees of potassium status.
Potassium chloride most commonly is administered. This theoretically could make the
acidosis worse, but no evidence indicates that administration of other potassium salts
such as phosphate or acetate is more effective.
b. Table 2. Infusion Rates of Potassium Chloride
Serum/Plasma K+
Potassium Chloride (KCL) Dose in Infusion Fluids
(mEq/L)
<2.5 mEq/L
Carefully monitored administration of 1 mEq/kg body weight
by separate infusion over 1 h
2.5-3.5 mEq/L

40 mEq/L

3.5-5 mEq/L

20 mEq/L

5-6 mEq/L

10 mEq/L (optional)

Over 6 mEq/L

Stop K+ and repeat level in 2 h

c. Bicarbonate: Although metabolic acidosis may be severe, no evidence supports

administration of IV sodium bicarbonate to improve outcomes; on the contrary, the
evidence indicates that IV bicarbonate may cause harm and delay recovery.34,35 Failure of
the acidosis to improve with treatment more likely reflects inadequate fluid and insulin
replacement. The only justification for using IV bicarbonate is acidosis sufficiently
severe to compromise cardiac contractility.
d. Other electrolytes: Although patients usually have an absolute deficit of phosphate and
magnesium, no evidence indicates that either needs to be replaced in patients with
diabetic ketoacidosis.
4. Regular assessment
a. Attention to detail is important to achieving a good outcome. Specifically designed
recording charts make the process of care much easier. Ideally, these charts include all
important measurements of clinical and biochemical status, fluid balance, and insulin
prescription.
b. Frequent review of neurologic status, at least hourly (or any time a change in level of
consciousness is suspected), is essential during the first 12 hours of diabetic
ketoacidosis treatment. Promptly treat any suspected cerebral edema.
Consultations
Consult a neurosurgeon if cerebral edema is suspected.
Diet
Once the child has recovered, he or she can resume a normal diet.