Pediatric Diabetic Ketoacidosis Management in the Era of Standardization

Ildiko H Koves; Catherine Pihoker

Disclosures

Expert Rev Endocrinol Metab. 2012;7(4):433-443. 

In This Article

Clinical & Biochemical Monitoring

Frequent meticulous clinical and biochemical monitoring of the DKA patient is essential so that timely adjustments and titrations to treatment can be made when indicated. There should be careful documentation of observations on a dedicated DKA flowchart.

Monitoring should include hourly neurological observations for GCS, symptoms of headache, recurring vomiting, change in neurological status such as anisocoria, age-inappropriate incontinence, increased drowsiness, irritability, focal neurological signs and vital sign changes such as inappropriate slowing of heart rate, decreasing oxygen saturation and rising pulse pressure – the 'Cushing triad' associated with CE. Hourly fluid balance assessment is essential.

Blood glucose checks should be hourly while on an insulin infusion. Blood urea nitrogen and serum electrolytes including sodium, corrected sodium, potassium, chloride, calcium, magnesium, phosphorus, osmolarity and blood gas (capillary, venous or arterial) may need to be checked every 2–4 h or more frequently, depending on the severity of DKA. The authors recommend BOHB measurement to be performed every 2 h until clearance, defined as ≤1 mmol/l.

Imaging Studies

Imaging is generally not recommended in the routine care of DKA. Head CT scans are commonly performed, but may actually adversely affect patient care. It may delay the much-needed insulin and/or CE therapy, and may make it more difficult for staff to closely monitor patients. CE is a clinical diagnosis. The majority of DKA patients have some degree of neuronal swelling, focal or diffuse radiological cerebral swelling without overt clinical CE warranting therapy.[52] Muir et al. published 75 episodes of DKA patients, and in severe DKA patients in coma secondary to CE, the initial head CT scans showed no abnormalities, emphasizing that it is a clinical and not a radiological diagnosis.[52] Coning during the process of CT scanning with no access to the much-needed mannitol therapy has to be considered. Head CTs should be reserved for patients who have shown no improvement following CE therapy in order to rule out possible other intracranial causes of neurologic deterioration, such as hemorrhage and thrombosis,[53,54] which would warrent additional therapy. Generally, such patients have more significant neurological signs than just mild confusion. These complications are fortunately exceedingly rare and do not justify the currently recognized practice of excessive head CT scanning shortly after presentation with an altered mental state.

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