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Published by: KAMAIR on Oct 03, 2010
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 Julie A Edge, Oxford, Feb 2004
BSPED Recommended DKA Guidelines
These guidelines for the management of Diabetic Ketoacidosis were originally producedby a working group of the British Society of Paediatric Endocrinology and Diabetes.Modifications have been made in the light of the guidelines produced by theInternational Society for Pediatric and Adolescent Diabetes (2000) and the recentESPE/LWPES consensus statement on diabetic ketoacidosis in children andadolescents (Archives of Disease in Childhood, 2004, 89: 188-194).We believe these guidelines to be as safe as possible in the light of currentevidence. However, no guidelines can be considered entirely safe as complicationsmay still arise. In particular the pathophysiology of cerebral oedema is still poorlyunderstood.Three aspects of the guidelines deserve further mention as being still subject tocontroversy:1. There is increasing (but not overwhelming) evidence that a fall in plasma sodiumconcentration during fluid treatment may be associated with the development of cerebral oedema. Hypotonic saline solutions should therefore not be used, and0.45% saline with dextrose is now the fluid of choice once the initial phase of treatment with normal saline is complete.2. There is some consensus that fluid rehydration should be delivered evenly over 48 hours, and that this practice may reduce the incidence of cerebral oedema.There is no direct evidence for this, and there may be disadvantages such asslowing down correction of the dehydration and acidosis. However, theinternational consensus group most recently recommended this rate of rehydration.
The initial intravenous insulin infusion dose is given as 0.1 units/kg/hour. Thereare some who believe that younger children (especially the under 5’s) areparticularly sensitive to insulin and therefore require a lower dose of 0.05units/kg/hour. There is no scientific evidence to alter the recommended larger dose which has proven efficacy in correcting hyperglycaemia and reversingketosis.
Any information relating to the use of these guidelines would be very valuable. Pleaseaddress any comments to :Dr. Julie Edge, Consultant Paediatric Endocrinologist, Department of Paediatrics, Level4, John Radcliffe Hospital, Headington, Oxford, OX3 9DU.
 Julie A Edge, Oxford, Feb 2004
Guidelines for the Management of Diabetic Ketoacidosis
PageA. General comments 1B. Emergency management1. Resuscitation 22. Confirm diagnosis 23. Investigations 2C. Full Clinical Assessment1. Assessment of dehydration 32. Conscious level 33. Physical examination 34. Role of PICU 35. Observations to be carried out 4D. Management 41. Fluids - volume 4type 5oral fluids 62. Potassium 63. Insulin 64. Bicarbonate 75. Phosphate 7E. Continuing management 8F. Cerebral oedemaFeatures 9Management 9G. Other complications and associations 10Glasgow Coma Scale Appendix 1Algorithm for Management Appendix 2
Always accept any referral and admit children in suspected DKA.
Always consult with a more senior doctor on call
as soon as you suspectDKA even if you feel confident of your management.
Remember : children can die from DKA
 They can die from -
Cerebral oedema. This is unpredictable, occurs more frequently in younger childrenand newly diagnosed diabetes and has a mortality of around 25%. The causes arenot known, but this protocol aims to minimise the risk by producing a slow correctionof the metabolic abnormalities. The management of cerebral oedema is covered onpage 8.
Hypokalaemia. This is preventable with careful monitoring and management
Aspiration pneumonia. Use a naso-gastric tube in semi-conscious or unconsciouschildren.These are general guidelines for management. Treatment may need modification tosuit the individual patient and these guidelines do not remove the need for frequentdetailed reassessments of the individual child's requirements.These guidelines are intended for the management of the
who have:
hyperglycaemia (BG >11 mmol/l)
pH < 7.3
Bicarbonate < 15 mmol/l
who are
more than 5% dehydrated
and/or vomiting
and/or drowsy
and/or clinically acidoticChildren who are 5% dehydrated or less and not clinically unwell usually tolerate oralrehydration and subcutaneous insulin.
Discuss this with the senior doctor on call

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