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Running Head: DIABETIC KETOACIDOSIS
Diabetic Ketoacidosis in Children with Type 1 Diabetes Mellitus
Stefanie Shorey
University of South Florida College of Nursing
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Abstract
Diabetic ketoacidosis is one of the leading causes of death in children with diabetes
mellitus type 1. The problem stems from undiagnosed diabetes and the inability of the caregivers
to identify symptoms of DKA early on. The leading reason that DKA has such a high death rate
is due to the risk of cerebral edema. Most treatments, like fluid and insulin replacement, although
necessary to correct DKA, lead to increase risks of cerebral edema if not given correctly. DKA
also poses risk factors for other diseases, such as arrhythmias and neurological impairment.
Introduction
Diabetes Mellitus is becoming ever more prevalent in the United States. Whether the
increase is due to better diagnoses, or the influx in the population’s weight, it is an important
subject for research. In the hospital, every patient has their blood sugar checked upon initial
admittance. Due to the difficulty in discovering if a child has diabetes, it is important to educate
parents of possible side effects of hyperglycemia and of the dangers of diabetic ketoacidosis
(DKA). Genetic factors are important for people to be aware of, and to make sure to present
physicians will full family medical history to determine the possibility of diabetes mellitus type
1. Most adults have diabetes mellitus type 2, due to increased weight, but children are susceptible
for diabetes mellitus type 2 as well, due to certain risk factors such as low socioeconomic status
and genetic factors contributing to insulin intake. Diabetes mellitus is constantly being seen in
hospitalized patients, who are not monitoring their glucose levels or are uneducated on the health
risks that come with having diabetes.
Pathophysiology
To be diagnosed with Diabetic Ketoacidosis (DKA), a patient has to have hyperglycemia,
with a glucose level above 200mg/dL, and metabolic acidosis, which needs a pH below 7.3. The
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patient will also have hyperketosis, high concentration of ketone bodies in the blood, and
hyperosmolality. DKA is usually the clinical manifestation seen in 30% of children for the initial
diagnosis of diabetes mellitus type 1. With DKA being the leading cause of hospitalization and
death in children with type 1 diabetes mellitus. Sometimes, children with poor metabolic control
and noncompliance with insulin shots, leads to recurring DKA in these children with diabetes
mellitus type 1. The main risk factors for DKA in diabetes mellitus type 2 are an age younger
than five years old, lack of health insurance, low BMI, and delayed treatment; in the United
States, 30% are Mexican-American and 40% are African-American. DKA can occur in patients
that take medications, such as corticosteroids and atypical antipsychotics, with no previous
diagnosis of diabetes mellitus.
Symptoms of DKA are polyphagia and polydipsia. Unlike hyperglycemia in diabetes
mellitus type 2, polyuria is not a typical symptom for diabetes mellitus type 1 patient mainly due
to the occurrences happening in children that have yet to be toilet trained. Weight loss is a major
sign in children suffering from diabetes mellitus type 1. Other symptoms, after DKA becomes
more severe, include appetite suppression, hyperventilation and Kussmaul respirations. Patients
will be very tired and close to coma due to increased hyperosmolality. This will caused edema,
and specifically cerebral edema, which is the main reason for death by DKA. It is difficult to see
dehydration in these children because they don’t have the same symptoms as adults because
dehydration is due to vomiting, rather than polyuria, so if DKA is suspected, volume
replacement should be started slowly, to reduce the danger of cerebral edema.
Severity of DKA is determined from findings clinical findings. First, it can be rated based
on the severity of the metabolic acidosis, which can be determined by finding the bicarbonate
levels and the acidity of the blood pH. Neurologic status is important to assess DKA, due to the
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increased risk for cerebral edema, and is usually assessed using the Glasgow coma scale. Loss of
fluid and how long the symptoms have been occurring also can indicate the severity of DKA.
It has been studied that patients who have DKA, have higher risks for other issues. They
have higher risk for cognitive impairment, deep venous thrombosis, aspiration due to lowered
level of consciousness and vomiting, cardiac arrhythmia due to hyper/hypokalemia, and
increased amylase and lipase values. It is important to assess a patient’s risk for diabetes mellitus
type 1, based on genetics, to avoid the onset of DKA and once diagnosed with diabetes mellitus,
the parent should be taught the proper maintenance of their child’s glucose levels and testing
urine regularly for ketone bodies.
Management of Diabetic Ketoacidosis
The usual treatments for DKA include insulin and correcting fluid/electrolyte imbalances.
Patients should also be monitored for cerebral edema. If patient is in shock, check for other
reasons besides hypovolemic shock, since that is rare in DKA patients. Patients should have fluid
replacement given slowly, to avoid the possibility of edema. Infusion rate is usually 10 mL/kg
per hour with normal saline or Ringer’s lactate with potassium, which solution is based on the
patient’s lab values. A patient should never be given too much fluid, because this will increase
the risk for cerebral edema. For the first 24 hours, the patient should not receive more than 3500
mL/m2 in fluid intake, both oral and parenteral.
After the first round of parenteral fluid, insulin in 0.45% saline IV begins at 0.1 unit/kg
per hour. In younger children, a smaller dose of 0.05 may be given. Studies have shown that
holding back on insulin for at least an hour, leads to a lesser risk of cerebral edema. The goal is
to stabilize serum insulin levels, to help overturn glucose and ketone production. The
hyperglycemia will also correct with the fluid replacement, lowering the concentration of
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glucose in the blood. After glucose returns to a normal level, IV infusion should be changed to
5% dextrose 0.9% saline or lactated Ringer’s solution, to prevent hypoglycemia from occurring.
Hopefully, serum sodium levels will correct during rehydration of the patient, but if not, then
proper replacement of the electrolytes would be considered after initial fluid and insulin
replacement. During insulin administration, potassium is pushed into cells, causing hypokalemia,
which means that potassium replacement is usually needed after the second hour of initial
treatment. During potassium therapy, ECGs are necessary to monitor heart rhythms.
Metabolic acidosis is more difficult to treat. Although during insulin and fluid
replacement, some of the ketone bodies are metabolized and flushed from the body. But, it is
very dangerous to use bicarbonate to treat a patient with DKA, because it could lead to cerebral
edema and extreme hypokalemia. Because of this, alkali therapy is reserved for patients that have
very acidic blood pH (less than 6.9) who are at a very high risk of cardiovascular issues.
Monitoring of a patient is determined on severity. If the patient is in severe DKA (with
vomiting), he/she would be placed on a pediatric ICU floor. Other patients, who do not have
vomiting, would be placed on any floor with an experienced diabetes team. Glucose should be
monitored hourly for the first 4-6 hours. Electrolytes and pH should be monitored hourly for the
first 3-4 hours, and then every 2 hours if deemed necessary. Accurate input and output is
necessary, and ECG monitoring if necessary. Insulin infusion can be discontinued if the patient’s
pH is above 7.3, glucose is less than 200 mg/dL, and is tolerating oral medication and food.
DKA treatment does not always mean that metabolic acidosis will be corrected. Mortality rates
for patients with pediatric DKA are 21-24%.
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Clinical Scenario
A 19 year old African American female was admitted to the hospital for uncontrolled
DKA. The troubling issue was that the patient had to have their second toe amputated due to
necrotic complications from uncontrolled hyperglycemia. The patient presented with flat affect
and lethargy. The patient had an ECG done when heart rate became abnormal and received
glucose checks every 4 hours. The patient had a wound VAC on the amputated toe site, and was
not clinically obese. The patient’s treatment was the same as suggested in the reviewed articles,
and they were being closely monitored for glucose levels. The patient is older, but has a history
of DKA, and should have her caregiver better educated on the risk factors that are attributed to
recurring DKA. The patient was not going to be discharged anytime soon, mainly because her
blood glucose levels were still too high, and she had to be monitored for any complications with
wound healing due to her diabetes. The nurse made sure to check her vitals, and upon noticing an
increased heart rate, she informed the physician who ordered an ECG. Although the patient’s
potassium levels were within normal ranges, an arrhythmia was found, which DKA occurrences
cause a risk for. Upon meeting this patient, I realized the importance of knowing the risks
associated with DKA and the importance of diagnosing diabetes mellitus type 1 in patients early
on, as well as the importance of education in the proper maintenance of glucose levels. A 19 year
old, already having her toe amputated, is a sign that there is a lack of knowledge in the United
States, and that, with such a high prevalence, diabetes awareness needs to be addressed.
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References
Haymond MD, Morey W. & Jeha MD, George S. (2014). Treatment and complications of
diabetic ketoacidosis in children. Uptodate website. Retrieved July 19, 2014 from
http://www.uptodate.com/contents/treatment-and-complications-of-diabetic-ketoacidosisin-children?source=search_result&search=diabetic+ketoacidosis&selectedTitle=3~150.
Haymond MD, Morey W. & Jeha MD, George S. (2014). Clinical features and diagnosis of
diabetic ketoacidosis in children. Uptodate website. Retrieved July 19, 2014 from
http://www.uptodate.com/contents/clinical-features-and-diagnosis-ofdiabeticketoacidosiinchildren?source=search_result&search=diabetic+ketoacidosis&seles
electedT=4~150#H9.