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Feb.09.2021

Diabetic Ketoacidosis (Pediatric Inpatient)

Clinical Description

Care of the hospitalized child experiencing severe insulin deficiency that results in profound hyperglycemia, fluid and electrolyte imbalance and production of ketones causing acidosis.

Key Information

It is critical to initially replace fluids, followed by insulin therapy.

Electrolyte levels may stabilize after initial fluid replacement; correct imbalance based on laboratory values.

Identification of the cause is key in treatment. The most common causes include new-onset diabetes, insulin deficiency, insulin pump site-related issues, knowledge deficit, psychosocial factors, insulin omission, infection, illness or stress.

A psychosocial assessment may be beneficial to identify underlying cause for those who are having difficulty with diabetes management and DKA (diabetic ketoacidosis) prevention.

Careful attention to neurologic status is necessary. Cerebral edema is a rare occurrence associated with a high mortality rate or severe permanent long-term complications.

The severity of the DKA (diabetic ketoacidosis) and acidemia, a young age, new onset diabetes and delay in treatment are key risk factors for cerebral edema. Signs and symptoms of cerebral edema include altered respiratory pattern, abnormal response to pain, change in mental status (e.g., restlessness, irritability, increased drowsiness), decorticate and decerebrate posturing, incontinence and cranial nerve palsy.

Serum beta-hydroxybutyrate is the preferred test for ketonemia; urine ketone analysis may not show current state.

Hyperglycemia resolves faster than ketoacidosis; ongoing insulin management is required even after glucose levels have fallen.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:

Fluid and Electrolyte Balance with Absence of Ketosis

B. Patient, family or significant other will teach back or demonstrate education topics and points:

Education: Overview
Education: Self Management
Education: When to Seek Medical Attention

Correlate Health Status

Correlate health status to:
- history, comorbidity, congenital anomaly
- age, developmental level
- sex, gender identity
- baseline assessment data
- physiologic status
- response to medication and interventions
- psychosocial status, social determinants of health
- barriers to accessing care and services
- child and family/caregiver:
- safety risks
- family interaction
- plan for transition of care

Diabetic Ketoacidosis

Signs/Symptoms/Presentation

abdominal pain
acetone breath
capillary refill delayed
coma
eyes sunken
fatigue
flushed cheeks
hyporeflexia
hypotonia
Kussmaul respirations
mental status altered
polyuria
profound polydipsia
shock
vomiting
unintentional weight loss
weakness

Vital Signs

heart rate increased or decreased
respiratory rate increased
blood pressure decreased

Laboratory Values

anion gap elevated
beta-hydroxybutyrate increased
bicarbonate decreased
blood glucose level elevated (greater than 200 mg/dL or 11 mmol/L)
blood ketones moderate to large
BUN (blood urea nitrogen) increased
magnesium level abnormal
pH decreased (less than 7.3)
phosphorus level abnormal
potassium level abnormal
serum creatinine increased
serum osmolality increased

Diagnostic Results

ECG (electrocardiogram) abnormal

Problem Intervention

Monitor and Manage Ketoacidosis

Provide intravenous fluid replacement to restore peripheral circulation, renal perfusion and electrolyte balance.
Administer insulin therapy to reverse ketogenesis and correct hyperglycemia; anticipate ongoing adjustment.
Anticipate initiation of dextrose-containing fluid therapy as blood glucose levels decrease.
Monitor and evaluate for changes in neurologic status that may indicate deterioration (e.g., headache, restlessness, increased drowsiness, incontinence, pupillary changes).
Monitor for cardiorespiratory pattern changes that may indicate worsening status.
Monitor trends for blood glucose levels, pH, electrolytes, vital signs, serum ketones, intake and output; advocate for treatment adjustment.
Acknowledge and validate significance of lifestyle impact and expectations (e.g., roles and identity, medication regimen, diet, exercise).

Associated Documentation

Fluid/Electrolyte Management
Glycemic Management

Education

CPG-Specific Education Topics

Overview

description
causes
signs/symptoms

Self Management

activity
blood glucose monitoring
fluid/food intake
medication management

When to Seek Medical Attention

unresolved/worsening symptoms

General Education Topics

General Education

admission, transition of care
orientation to care setting, routine
advance care planning
diagnostic tests/procedures
diet modification
opioid medication management
oral health
medication management
pain assessment process
safe medication disposal
tobacco use, smoke exposure
treatment plan

Safety Education

call light use
equipment/home supplies
fall prevention
harm prevention
infection prevention
MDRO (multidrug-resistant organism) care
personal health information
resources for support

References

American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
Andrade-Castellanos, C. A.; Colunga-Lozano, L. E.; Delgado-Figueroa, N.; Gonzalez-Padilla, D. A. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database of Systematic Reviews. 2016;(1) doi:10.1002/14651858.CD011281.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
Davis, G. M.; Galindo, R. J.; Migdal, A. L.; Umpierrez, G. E. Diabetes Technology in the Inpatient Setting for Management of Hyperglycemia. Endocrinology Metabolic Clinics of North America. 2020;49(1), 79-93. doi:10.1016/j.ecl.2019.11.002 Source[Expert/Committee Opinion]
Gallo de Moraes, A.; Surani, S. Effects of diabetic ketoacidosis in the respiratory system. World Journal of Diabetes. 2019;10(1), 16-22. doi:10.4239/wjd.v10.i1.16 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Glaser, N.; Kuppermann, N. Fluid treatment for children with diabetic ketoacidosis: How do the results of the pediatric emergency care applied research network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (FLUID) Trial change our perspective?. Pediatric Diabetes. 2019;20, 10-14. doi:10.1111/pedi.12795 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Kharode, I.; Coppedge, E.; Antal, Z. Care of children and adolescents with diabetes mellitus and hyperglycemia in the inpatient setting. Current Diabetes Reports. 2019;19, 85. doi:10.1007/s11892-019-1205-7 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Kreider, K. E.; Gabrielski, A. A.; Hammonds, F. B. Hyperglycemia syndromes. Nursing Clinics of North America. 2018;53(3), 303-317. doi:10.1016/j.cnur.2018.04.001 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Kubacka, B. T. Acute hyperglycemic emergencies: Diabetic ketoacidosis and hyperosmolar hyperglycemic state. Nursing2019 Critical Care. 2019;14(2), 10-21. doi:10.1097/01.CCN.0000553076.18411.12 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Long, B.; Koyfman, A. Emergency medicine myths: Cerebral edema in pediatric diabetic ketoacidosis and intravenous fluids. Journal of Emergency Medicine. 2017;53(2), 212-221. doi:https://doi.org/10.1016/j.jemermed.2017.03.014 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
Marks, B. E.; Wolfsdorf, J. I. Monitoring of pediatric type 1 diabetes. Frontiers in Endocrinology. 2020;11(128) doi:10.3389/fendo.2020.00128 Source[Review Articles]
National Institute for Health and Care Excellence. (2015). Diabetes (type 1 and type 2) in children and young people: Diagnosis and management. Source[Quality Measures,Clinical Practice Guidelines]
Panagiotopoulos, C.; Hadjiyannakis, S.; Henderson, M. Type 2 diabetes in children and adolescents. Canadian Journal of Diabetes. 2018;42, S247-S254. doi:10.1016/j.jcjd.2017.10.037 [Quality Measures,Clinical Practice Guidelines]
Pratiwi, C.; Mokoagow, M. I; Kshanti, I. A. M.; Soewondo, P. The risk factors of inpatient hypoglycemia: A systematic review. Heliyon. 2020;6 doi:10.1016/j.heliyon.2020.e03913 Source[Review Articles]
Wherrett, D. K.; Ho, J.; Huot, C.; Legault, L.; Nakhla, M.; Rosolowsky, E. Type 1 diabetes in children and adolescents. Canadian Journal of Diabetes. 2018;42, S234-S246. doi:10.1016/j.jcjd.2017.10.036 [Quality Measures,Clinical Practice Guidelines]
Wolfsdorf, J. I.; Glaser, N.; Agus, M.; Fritsch, M.; Hanas, R.; Rewers, A.; Sperling, M. A.; Codner, E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatric Diabetes. 2018;19(Suppl 27), 155-177. doi:10.1111/pedi.12701 [Quality Measures,Clinical Practice Guidelines]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.