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Diagnosis and treatment process of diabetic ketoacidosis in children

 

Diabetic ketoacidosis (DKA) is a common acute complication of diabetes in children, more common in type 1 diabetes, characterized by hyperglycemia, hyperketonemia and metabolic acidosis.

 

Clinical manifestations: may include polyuria, polydipsia, weight loss, abdominal pain, vomiting, Kussmaul respirations, altered mental status, etc.

 

Diagnostic criteria (all three criteria must be met):

1. Any blood glucose >11 mmol/L;

2. Venous pH <7.3 or serum HCO3- <18 mmol/L;

3. Ketonuria (qualitative ++ or above) or ketonemia (β-hydroxybutyrate ≥ 3 mmol/L).

 

Severity grading:

Mild: pH 7.2 to <7.3 or HCO3- 10 to <18 mmol/L;

Moderate: pH 7.1 to <7.2 or HCO3- 5 to <10 mmol/L;

Severe: pH <7.1 or HCO3- <5 mmol/L.

 

 

Treatment:

Rapid rehydration phase: 10-20 ml/kg of normal saline, intravenous infusion for 30-60 minutes (if there is shock, it can be infused within 10-15 minutes, and the total amount in the first hour should not exceed 40 ml/kg).

 

Maintenance rehydration phase: 0.45-0.9% NaCl, complete rehydration in 24-48 hours (based on the physiological needs, the cumulative loss can be replenished quickly and then slowly in 24 hours, or it can be given at a constant speed in 48 hours. The specific situation needs to be combined with the actual situation of the child to appropriately speed up or slow down the infusion speed), and potassium should be supplemented at the same time (urine should be supplemented if the blood potassium is <5.5 mmol/L).

 

Use of intravenous insulin: Insulin 0.05-0.1 U/kg·h is given 1 hour after the start of rehydration therapy (it can only be used after the shock is basically corrected, and the younger the age, the smaller the amount should be used).

 

Use of sugar solution: When blood sugar drops to 14-17 mmol/L, sugar solution is used. Initially, 5% sugar solution can be given (maximum peripheral 12.5%). The blood sugar drop rate is preferably 2-5 mmol/L.h, and the final blood sugar control is preferably 8-12 mmol/L.

 

Indications for discontinuation of intravenous insulin: When blood sugar drops below 11.1 mmol/L, blood pH>7.3, blood HCO3-≥ 15 mmol/L, β-hydroxybutyric acid < 1 mmol/L, intravenous insulin can be discontinued (use rapid-acting insulin subcutaneously 15 minutes before discontinuation). (Note: The 2022 ISPAD (International Society for Pediatric and Adolescent Diabetes) guidelines state that as long as the child is clinically well, ketoacidosis has resolved, and can tolerate oral fluids, they can transition to subcutaneous insulin injections.)

 

 

References:
  1. 中华医学会儿科学分会内分泌遗传代谢学组,中国医师协会儿科医师分会内分泌遗传代谢学组,中国医师协会青春期健康与医学专业委员会,等.儿童糖尿病酮症酸中毒诊疗指南(2024)[J].中华儿科杂志, 2024, 62(12):1128-1136.
  2. 王天有. 诸福棠实用儿科学. 第9版.  北京: 人民卫生出版社, 2022.
  3. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022 Nov;23(7):835-856.