Our goal as primary care physicians is to make the diagnosis of Type 1 Diabetes or Diabetic Ketoacidosis at the earliest opportunity and then immediately arrange for inpatient expert follow up at a tertiary care center.
Twenty-five percent of patients with a new diagnosis of diabetes present with diabetic ketoacidosis; a missed diagnosis of diabetes is the most common cause, especially in young children. [from Pediatric Diabetic Ketoacidosis Emergency Department Care of emedicine.medscape.com]
What follows are excerpts of Pediatric Type 1 Diabetes Mellitus Clinical Presentation Updated: Apr 27, 2017 from emedicine.medscape.com:
Symptoms of ketoacidosis
These symptoms include the following:
- Severe dehydration
- Smell of ketones
- Acidotic breathing (ie, Kussmaul respiration), masquerading as respiratory distress
- Abdominal pain
- Drowsiness and coma
What follows are only excerpts from the Diabetes Mellitus Guideline. Please see the complete protocol] on diabetic ketoacidosis from the Royal Children’s Hospital Melbourne:
Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. It may be the first presentation for a child with previously undiagnosed diabetes. It can also be precipitated by illness, or poor compliance with taking insulin.
All patients presenting with a blood glucose level (BGL) ≥ 11.1mmol/l [200 mg/dl] should have blood ketones tested on a capillary sample using a bedside OptiumTM meter. If this test is positive (>0.6 mmol/l), assess for acidosis to determine further management. Urinalysis can be used for initial assessment if blood ketone testing is not available.
The biochemical criteria for DKA are:
1. Venous pH < 7.3 or bicarbonate <15 mmol/l
2. Presence of blood or urinary ketones
If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see ‘ new presentation, mildly ill‘ below).
If ketones are negative, or the pH is normal in the presence of ketones, patients can be managed with subcutaneous (s.c.) insulin (see ‘ new presentation, mildly ill‘ in this protocol).
Management of DKA
Children and adolescents with DKA should be managed in a unit that has:
- Experienced nursing staff trained in the monitoring and management of DKA
- A paediatric endocrinologist, paediatrician or paediatric critical care specialist with training and expertise in the management of DKA. Where such expertise is not available on-site, telephone advice should be sought from the appropriate specialists
- Access to laboratories for frequent and timely evaluation of biochemical variables
- Not all patients in DKA require fluid boluses. Remember acidosis itself results in poor peripheral perfusion and confounds accurate assessment of dehydration. Peripheral perfusion will improve with correction of the acidosis (with insulin)
- If hypoperfusion is present, give 0.9% saline at 10 ml/kg and reassess. If central capillary refill remains > 2 seconds, a further bolus of 10ml/kg 0.9% saline may be given
- Patients with DKA rarely require >20 ml/kg in total as a bolus. The potential for harm with over-zealous fluid administration must be remembered. Please discuss the use of additional boluses (> 20ml/kg total) with the endocrinologist on call or local paediatrician
Initial fluid replacement:
Commence rehydration with normal saline + potassium (see section 4 below for K+ replacement). The fluid type will need to be adjusted dependent on ongoing glucose, Na and K levels.
There are many hazards of diabetic ketoacidosis and these are all detailed with treatment recommendations in the protocol. One of the most feared complications is:
3. Cerebral Oedema
Some degree of subclinical brain swelling is present during most episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs suddenly, usually between 6 and 12 hours after starting therapy (range 2 – 24 hr). Mortality or severe morbidity is very high without early treatment.
Slow correction of fluid and biochemical abnormalities. Optimally, the rate of fall of blood glucose and serum osmolality should not exceed 5 mmol/l/hr, but in children there is often a quicker initial fall in glucose. Patients should be nursed head up.
- Risk factors: first presentation, long history of poor control, young age ( < 5 yr)
- No sodium rise as glucose falls, hyponatraemia during therapy, initial adjusted hypernatraemia
- Headache, irritability, lethargy, depressed consciousness, incontinence, thermal instability.
- Very late signs – bradycardia, increased BP and respiratory impairment.
Mannitol 20% 0.5 g/kg (range 0.25–1.0 g/kg) i.v. over 20 minutes. Give immediately when the clinical diagnosis is suspected – do not delay for confirmatory brain scan. The dose can repeated if no initial response after 30 mins – 2 hours
Reduce fluid input by 1/3 in the first instance. Nurse head up
Transfer immediately to ICU level care.
Please note that the above are only excerpts, you should go to this link for the complete outstanding protocol.
As I said at the beginning of the post, our goal as primary care physicians is to make the diagnosis of Type 1 Diabetes or Diabetic Ketoacidosis at the earliest opportunity and then immediately arrange for expert inpatient follow up care.