DKA MANAGEMENT

• . Diabetes occurs either because the body

does not produce enough insulin, or because
cells do not respond to the insulin that is
produced (insulin resistance)
 SYMPTOMS AND SIGNS
More Common Less Common Severe (Diabetic
ketoacidosis)
Weight loss Excessive hunger Frequent vomiting and
acute abdominal pain
Polyuria – in younger children Blurred vision Flushed Acetone
bedwetting is common cheeks smell on
breath
Excessive thirst Mood changes Dehydration with
continuing polyuria
Tiredness - not wanting to Skin infections Decreased level of
work or play consciousness
Oral or vaginal thrush Kussmaul respiration
(deep, rapid, sighing)
Abdominal pain Coma Shock
 MISDIAGNOSED
• Pneumonia or asthma (laboured breathing),
as appendicitis or gastroenteritis (abdominal
pain, vomiting), as a serious infection such as
malaria, typhoid, HIV/AIDS, tuberculosis, or
meningitis (coma etc.), as a urinary tract
infection (urinary frequency), or as
malnutrition (weight loss, tiredness).
Diagnosis of diabetes is made when:
• Symptoms + random BGL ≥ 11.1 mmol/L (≥200 mg/dl)
• (or)
• Fasting BGL ≥ 7mmol/L (≥ 126 mg/dl)
• (or)
• 2 hour post load glucose ≥ 11.1 mmol/l (≥ 200 mg/dl)
during an oral glucose tolerance test 75 gm glucose or 1.75
g/kg of body weight to a maximum of 75 g is given as a
sweet drink after fasting
• In the absence of clear symptoms, diagnostic testing should
be repeated on a separate day. If resources are limited and
blood glucose testing is unavailable, diagnosis can be made
by testing urine for high levels of glucose and ketones
 TYPES OF DIABETES
• Type 1 Diabetes
• Type 2 Diabetes
• Other Types of Diabetes
– Malnutrition related diabetes and fibrocalculous
pancreatopathy
– Atypical diabetes
– Neonatal Diabetes
– MODY
– Diabetes associated with syndromes such as Down
Syndrome, Prader-Willi Syndrome.
– Gestational diabetes
 MANAGEMENT OF DIABETIC KETOACIDOSIS

The biochemical criteria for DKA are:

• Hyperglycaemia (blood glucose >11mmol/l
(~200 mg/dl)) In rare cases, blood glucose can
be < 11 mmol/l; “euglycemic ketoacidosis”
• Venous pH <7.3 or bicarbonate <15 mmol/l
• Ketonaemia and ketonuria
• DKA is a medical emergency
• Correction of the clinical and chemical
changes must occur gradually
• Fluid replacement is initially more important
than insulin therapy
• Insulin therapy is needed to correct the
acidosis and hyperglycaemia
 INITIAL ASSESSMENT AND
MONITORING
• Clinical assessment
– Severity of dehydration
– Level of consciousness
– Evidence of infection
Weigh the child.
• Measure blood glucose
• Measure ketones
• Laboratory –CBP,Blood Glucose,RFT,SE,AVG,CRP,
HbA1c
Monitoring
• Record hourly: heart rate, blood pressure,
respiratory rate, level of consciousness, glucose
meter reading
• Monitor urine ketones in every sample of urine
passed
• Record fluid intake, insulin therapy and urine
output
• Repeat blood urea and electrolytes every 2-4
hours
• Measure blood ketones (β-hydroxybutyrate) if
possible
 CORRECTION OF SHOCK

• Treat Shock aggressively,treat dehydration gradually

• ABC
• Oxygen
• Set up a large IV cannula/intraosseous
access/nasogastric tube
• 20mL/kg bolus infused as quickly as possible.
Additional 10mL/kg boluses may need to be
administered
• If the only access is by nasogastric tube, give the
same volume of fluid over 60 minutes (Normal (0.9%)
Saline, half strength Darrow’s Solution with Dextrose
or Oral Rehydration Solution (ORS)) until perfusion
• Shock must be adequately treated before
proceeding. There should be good peripheral
perfusion and adequate blood pressure.
• Fluid replacement, insulin therapy and
potassium replacement will slowly correct the
acidosis, deficits in electrolytes, and the
hyperglycaemia over 24 hours. Dehydration
should be slowly corrected over 48 hours.
 FLUID REPLACEMENT
• If there is no shock but dehydration is ≥5%, give an
IV bolus of 10 ml/kg Normal Saline (0.9%) over 1
hour
• Fluid therapy should begin with deficit
replacement plus maintenance fluid requirements.
• Rehydrate the child with Normal Saline (0.9%). Aim
to provide maintenance fluid and to replace any
deficit (up to 10%) over 48 hours
• Once the blood glucose level is <15 mmol/l (<270
mg/ dl), add glucose (dextrose) to the saline (add
100ml of 50% glucose/dextrose to every litre of
• If intravenous/osseous access is not available,
rehydrate orally with Oral Rehydration Solution
(ORS). This can be done by nasogastric tube at
a constant rate over 48 hours. If a nasogastric
tube is not available, give ORS by oral sips at a
rate of 5 ml/kg per hour.
• When oral fluid is tolerated, IV fluid should be
reduced accordingly
• The more ill the child, the slower the
rehydration should be because of the risk of
developing cerebral oedema.
 INSULIN TREATMENT

• It should be started 1-2 hours after initiating

fluid therapy once the shock has been corrected
• Intravenous infusion of 0.1 unit/kg/hour
• In children under 5 years of age, and also
patients with a hyperglycaemic hyperosmolar
state (HHS ) consider using a lower rate of
insulin delivery
• If insulin cannot be given intravenously by a side
drip or infusion pump, use deep subcutaneous
or intramuscular insulin
• Sometimes higher concentrations of
glucose/dextrose are needed to maintain the
blood glucose between 10-15 mmol/l (180-
270mg/dl) while the metabolic acidosis is still
being cleared. Ketones can be excreted into the
urine for several hours after the pH has
normalized.
• Continue to give 0.05-0.1 U/kg/hour insulin until
ketones have been cleared or pH is normalized
• Aim for a glucose reduction of about 5 mmol/l
(90 mg/dl) per hour.
 POTASSIUM REPLACEMENT
needed for every child in DKA.
• Measure blood potassium level /ECG
• Monitor renal status
• Replace potassium by adding potassium chloride to the 48-
hour replacement IV fluids at a concentration of 40 mmol/L
• The maximum recommended rate of intravenous
potassium replacement is usually 0.5 mmol/kg/hour
• If hypokalaemia persists, the rate of insulin infusion can be
reduced.
• ORS, potassium suppliment
 ROLE OF BICARBONATE

• child is in shock with severe acidaemia (pH <

6.9)
• Life threatening hyperkalemia
• 1-2 mmol/kg IV over 60 minutes
 TREATMENT OF INFECTION
• broad spectrum antibiotics.
 CEREBRAL OEDEMA

• The rapidly rising intracranial pressure

• Change in neurological status
• Specific neurological signs
• Decreased oxygen saturation (cyanosis).
• TREAT URGENTLY
• hypoglycaemia
• rule out other possible intracerebral causes of
neurological deterioration, especially thrombosis
or haemorrhage
 MONITORING THE CHILD

• If biochemical parameters of DKA do not

improve consider infection or errors in insulin
preparation
• If replacing fluid orally, ensure that the child
has ORS or fruit juice once the glucose is
below 15 mmol/l (270 mg/dl).
 TRANSITIONING TO SUBCUTANEOUS INSULIN

• Once the DKA has been adequately treated

(hydration corrected, glucose controlled,
ketones cleared) the child can be transitioned
to subcutaneous insulin. The first SC dose of
short-acting insulin should be given 1-2 hours
before stopping the insulin infusion.
 INSULIN TREATMENT
Honeymoon Phase
This has been defined as insulin requirements of
less than 0.5 units per kg of body weight per
day with an HbA1c < 7% (53 mmol/mol).
Insulin requirements
• Pre-pubertal children usually require 0.7-1.0
IU/kg/day.
• During puberty above 1 and even up to 2
U/kg/day.
Insulin Preparations Onset of Peak of Duration When to give
type Action action of action

Rapidactin Aspart, Glulisine, Lispro 15-30 1-2 3-5 hours immediately

g minutes hours prior to meal

Shortacting Actrapid, Humulin R, 30-60 2-4 5-8 hours 30 minutes

(regular) Insuman Rapid minutes hours prior to meal

Intermedia Humulin NPH, Protaphane, 2-4 hours 4-10 12-24 30 minutes

teacting Insulatard, hours hours prior to meal

Longacting Detemir 1-2 hours 6-12 20-24 once or twice

hours hours daily

Glargine 2-4 hours relatively 24 hours once or twice

peakless or less daily

Mixed Rapid/longacting mix or 30 4-12 8-24 hours 30 minutes

Short/longacting mix 30/70 minutes hours prior to meal
or 25/75
The two most common regimens used are:
• Twice-daily insulin
• Basal bolus regimen (the preferred option)
 GUIDELINES ON INSULIN DOSAGE
Day 1
• Give short-acting (regular) insulin (0.1 U/kg) every second hour
until blood glucose is < 11 mmol/l, then every 4-6 hours. If
hourly monitoring of blood glucose cannot be provided, begin
with half the above dose.
Day 2 (from morning/breakfast):
Total daily dose 0.5-0.75U/kg/day.
A. TWO INJECTIONS PER DAY
• A starting point is to give two-thirds of the total daily insulin in
the morning before breakfast and one-third before the
evening meal.
• On this regimen, at the start, approximately one-third of the
insulin dose may be short-acting (regular) insulin and
approximately two-thirds may be intermediate-acting insulin
• BASAL BOLUS REGIMEN -also called Multiple Daily
Injections (MDI)
• If short-acting (regular) and intermediate-acting
insulin is used, give:
– 70% of the total daily dose as short-acting (regular)
insulin (divided up between 3-4 pre-meal boluses)
– 30% of the total daily dose as a single evening injection
of intermediate-acting insulin
• If short-acting (regular) and long-acting analogue
insulins are used, give:
– 50% of the total daily dose as short-acting (regular)
insulin (divided up between 3-4 pre-meal boluses)
– 50% of the total daily dose as a single evening
injection of long-acting analogue insulin.
(Sometimes this dose does not last for 24 hours
and then can be split into two doses morning and
evening).
– Mixing Insulins in the same syringe
– Giving an injection with a syringe
– Injection sites
– Insulin storage
 BLOOD GLUCOSE MONITORING
• Ideal 4-6 times a day
• couple of tests a week can assist
management, and two tests per day gives
much useful information.
• Recommended target blood glucose levels:
Before meals 4-7 mmol/l (72-126 mg/dl)
After meals 5-10 mmol/l (90-180 mg/dl)
At bed time 6-10 mmol/l (108–180 mg/dl)
At 3am 5-8 mmol/l (90-144 mg/dl
THANK YOU 