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.