diabetic ketoacidosis

Management Guideline
for
Diabetic Ketoacidosis
of
Childhood and Adolescence

30 2553

 diabetic ketoacidosis

Management Guideline for Diabetic Ketoacidosis (DKA)

of Childhood and Adolescence

(acidosis) (ketonemia)
(hyperglycemia) (insulin)

1. (glucose)

glycogenolysis gluconeogenesis
2. Ketosis (lipolysis) (ketogenesis)
(ketonuria)
3. (hypertriglyceridemia)
(free fatty acid)
4. Osmotic diuresis
(glycosuria)
(electrolyte imbalance)
5. (dehydration)

(osmotic diuresis)

1 (type 1 diabetes)
DKA

Kussmaul breathing (metabolic
acidosis)

 diabetic ketoacidosis

(polydipsia)
(polyuria) (nocturnal enuresis)

(polyphagia) (weight loss) (weakness)
DKA
1. : (plasma glucose) >200 ./. (>11
/.)
2. (acidosis): HCO2 <15 /. venous pH <7.3
3.
DKA

7.20-7.29
10.0-14.9

DKA

7.10-7.19
5.0-9.9

<7.10
<5

Venous pH
Serum bicarbonate (/.)

1.

1.1
1.2 (assessment of clinical severity of dehydration)
DKA 5-10%

(3-5%)
(5-7%)
(7-10%)
>10%

skin turgor
skin turgor
(hyperpnea) capillary refill 2

 diabetic ketoacidosis

DKA

DKA severe DKA
(7-10%)
1.3
blood glucose ( blood ketone )
urine ketone glucose
serum BUN, creatinine, electrolytes, calcium, phosphate, magnesium
venous blood gases pH, pCO2, base excess
2. DKA
2.1 (hemoculture)
2.2 (urinalysis)
2.3 (chest X-ray)
3.
3.1 HbA1c
3.2 Insulin C-peptide ( insulin)
3.3 Anti-glutamic acid decarboxylase (Anti-GAD), islet cell antigen 512 antibody
(IA2), insulin autoantibody (IAA), islet cell antibody (ICA)
3.2 3.3 ()
DKA
1.
2. metabolic acidosis ketosis
3.
4. DKA
5. DKA
DKA
1.
1.1 DKA
DKA 5-10% mild
DKA 3-5%, moderate DKA 5-7% severe DKA 7-10%

 diabetic ketoacidosis

1.2 normal saline (NSS) Ringer lactate solution (RLS)

10-20 ./. bolus 15-30

1.3 NSS 10-20 ././. 1-2

1.4 fluid deficit 48

Maintenance 24 . + fluid deficit (5-10%) = (./.)
24
48
NSS 4-6 ( hypernatremia
NSS/2) ()

24 1.5-2.0 maintenance
( 4 //)
ideal weight for height

( osmotic diuresis)
1.5 KCl initial rehydration
/ hyperkalemia (serum K >6 /.) KCl 3
1.6 fluid balance
2-3
1.7 moderate severe DKA
( mild DKA )
2.
initial rehydration 1-2 . regular insulin (RI)
continuous low-dose intravenous insulin infusion method
RI 0.1 /./. insulin infusion RI 50 NSS 50
. 1 . RI 1 insulin infusion infusion pump
side-line

 diabetic ketoacidosis

infusion set insulin infusion

10-20 . saturate binding site

1. insulin IV bolus insulin infusion

2. initial rehydration RI infusion
50-200 ./. dehydration RI
75-100 ./.
bedside
blood glucose 1
250-300 ./. 5% dextrose
5% dextrose in 0.45% NaCl
Insulin infusion acidosis ketonemia
dextrose
150-250 ./. ( 150
./.) RI ( 0.05 /./.)
dextrose 7.5-12.5% ketonemia acidosis
RI RI 0.05 /./.
70 ./. 10% glucose 2 ./.
glucose

1. insulin infusion RI
insulin infusion -1
rebound hyperglycemia ( rapid-acting insulin aspart lispro
rapid-acting insulin insulin infusion 10-15 ) (
DKA)
2. insulin infusion infusion pump
insulin intramuscular (IM) insulin administration RI 0.1 /
. 1 250-300 ./.
RI 0.25-0.5 /. (subcutaneous) 4-6

 diabetic ketoacidosis

severe acidosis, peripheral perfusion

RI
3. (potassium, K)
DKA total
body K K potassium
K K initial
rehydration insulin infusion K 40 /.
potassium ( 2.5 /.) K initial rehydration (
K 0.5 /./.)

K <2.5 /. KCl 0.5 /./.

RI K >2.5 /. EKG KCl
K 0.5 /./.
4. (sodium, Na)
DKA
corrected serum sodium
Corrected Na = Na (mmol/L) + [Plasma glucose (mg/dL)100]x 1.6
100
initial rehydration NSS 10 ././.
NSS 4-6
electrolytes
corrected serum Na 150 /.
hypernatremia hyperosmolar Na glucose
cerebral edema
48-72 24 200300 ./.
0.45-0.9% NaCl (
0.9% NaCl

 diabetic ketoacidosis

0.45% NaCl) osmolality

DKA triglyceride
pseudohyponatremia
5. bicarbonate (HCO3)
5.1 acidosis dehydration insulin
bicarbonate HCO3


Persistent severe acidosis pH <6.9 HCO3 <5 /.
initial rehydration insulin infusion NaHCO3 1-2
/. intravenous drip 1
5.2 bicarbonate cerebral edema, paradoxical
cerebral acidosis, shift to the left of oxyhemoglobin dissociation curve peripheral oxygen
availability severe hypokalemia K
EKG
6. (phosphate, PO4)
DKA acidosis
RI
DKA
(hypocalcemia)
1 ./.
KH2PO4 20-30 /.

7.
DKA
ICU
7.1 vital signs neurological signs 1
7.2 blood glucose 1
7.3 serum electrolytes, blood gases () 2-4
7.4 intake output 2-4

 diabetic ketoacidosis

7.5 serum ketone urine ketone 6

250 ./.
7.6 serum BUN, Cr, Ca, P severe DKA
7.7 flowsheet
7.8 nasogastric tube urinary catheter
8. DKA
DKA

urinalysis, urine culture, hemoculture, tuberculin test

9.
DKA
9.1 Hypoglycemia continuous insulin infusion

9.2 Persistent acidosis HCO3 <10 /.

8-10 hyperglycemia
- RI RI RI
intravenous infusion
-
-
- hyponatremia, hypokalemia hyperchloremic acidosis chloride

- RI RI
9.3 Hypokalemia K acidosis
K shift K K
K muscle
weakness
9.4 Intracranial complication (cerebral edema)
4-12
<5
bicarbonate BUN

 diabetic ketoacidosis

decreased sensorium,
, disorientation, agitation, pupillary change,
ophthalmoplegia, papilledema,

(diagnostic criteria)
Abnormal motor or verbal response to pain
Decorticate or decerebrate posture
Cranial nerve palsy (especially III, IV, and VI)
Abnormal neurogenic respiratory pattern (e.g., grunting, tachypnea, Cheyne-Stokes
respiration, apneusis)
(major criteria)
Altered mentation/fluctuating level of consciousness
Sustained heart rate deceleration (decrease more than 20 beats per minute) not attributable
to improved intravascular volume or sleep state
Age-inappropriate incontinence
(minor criteria)
Vomiting
Headache
Lethargy or not easily arousable
Diastolic blood pressure >90 mmHg
Age <5 years
1
2 1 2
<5 severe DKA
1) ICU
2)
-
- 2/3

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 diabetic ketoacidosis

- 20% Mannitol 0.5-1 /. 20

30 2
- mannitol hypertonic saline (3% NaCl) 5-10
./. 30
- Intubation coma aggressive
hyperventilation PCO2 <22 mmHg
- Monitor neurological signs CT brain
stabilize
DKA
1. 12-24 (
) metabolic blood
glucose < 300 ./., pH >7.3 serum HCO3 >15 /. ketosis
mild acidosis
maintenance + deficit
2. insulin infusion
metabolic criteria resolution of DKA (blood glucose < 200 ./., venous pH >7.3
serum HCO3 >15 /.) RI 0.2-0.5 /. 6

insulin -1
3. (subcutaneous)
RI 0.25-0.5 /./ 3
1-2 DKA acidosis RI
intermediate acting insulin (NPH) (prepuberty)
total daily dose (TDD) insulin 0.7-1.0 /./
1.0-1.2 /./ 2 3 ( NPH : RI
2 : 1) 1 3 ( NPH : RI 1 : 1)
basal-bolus regimen 24 . (TDD)
TDD basal insulin ( glargine detemir)
rapid-acting insulin ( aspart lispro) ( rapid-acting
insulin 15-20% TDD)

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 diabetic ketoacidosis

4. balanced diet
50-55 25-30 15-20
5.
blood glucose 3
hypoglycemia urine ketone blood glucose >200 ./.

70-180 ./.
6. DKA

6.1
6.2 Insulin insulin
6.3
6.4
6.5 hypoglycemia hyperglycemia
6.6

1-2

1. Klein M, Sathassivam A, Navoa P, Rapaport R. Recent consensus statements in pediatric

endocrinology. Endocrinol Metab Clin North Am 2009;38:811-825.
2. Edge JA. Guidelines for the management of diabetic ketoacidosis. Oxford, 2009.
3. Cooke DW, Plotnick L. Management of diabetic ketoacidosis in children and adolescents.
Pediatr Rev 2008;29:431-435.
4. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and
adolescents: A consensus statement from the American Diabetes Association. Diabetes Care
2006;29:1150-1159.
5. Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, Rosenbloom A, Sperling M,
Hanas R. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes
2009;10 Suppl 12:118-133.

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