Diabetic Ketoacidosis

Katherine Cashen; Tara Petersen

doi:10.1542/pir.2018-0231

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Katherine Cashen, DO*
Tara Petersen, MD, MSEd^†

^*Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI
^†Division of Critical Care, Department of Pediatrics, Children’s Hospital of Wisconsin/Medical College of Wisconsin, Milwaukee, WI

AUTHOR DISCLOSURE
Drs Cashen and Petersen have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Abbreviations:

DKA:: diabetic ketoacidosis
GCS:: Glasgow Coma Scale
PECARN:: Pediatric Emergency Care Applied Research Network
T1DM:: type 1 diabetes mellitus
T2DM:: type 2 diabetes mellitus

Practice Gaps

Clinicians should be aware of the etiology and clinical presentation of diabetic ketoacidosis.
Clinicians should understand the appropriate management and risks associated with treatment of children with diabetic ketoacidosis.

Objectives

After completing this article, readers should be able to:

Understand the etiology of diabetic ketoacidosis (DKA).
Understand the basic clinical presentation, diagnostic tests, and management of DKA.
Recognize the risks associated with fluid and electrolyte therapy in patients with DKA.
Understand the causes of recurrent DKA.

Introduction

Diabetic ketoacidosis (DKA) occurs when there is a relative or absolute decrease in circulating insulin levels in relation to an increase in counterregulatory hormone levels. In response to this imbalance, normal physiologic mechanisms are exaggerated, resulting in hyperglycemia, hyperosmolality, ketosis, and acidosis. (1) The biochemical criteria for the diagnosis of DKA are hyperglycemia (blood glucose level >200 mg/dL [>11.1 mmol/L]), venous pH less than 7.3 or serum bicarbonate level less than 15 mEq/L (<15 mmol/L), and ketonemia (blood β-hydroxybutyrate concentration ≥3 mmol/L) or moderate or severe ketonuria. (1)(2)(3)

Overall, the most common cause of DKA is new-onset type 1 diabetes mellitus (T1DM). DKA can also be seen in children with T1DM and infection, other intercurrent illness, or inadequate insulin administration. Children with type 2 diabetes mellitus (T2DM) may also present in DKA. High-dose corticosteroids, atypical antipsychotic agents, diazoxide, and immunosuppressive medications have been reported to precipitate DKA in patients without a diagnosis of T1DM. (4)(5)

Treatment of DKA involves careful fluid resuscitation, insulin administration, electrolyte replacement, and close monitoring for signs of cerebral edema. This review focuses on the epidemiology, pathogenesis, diagnosis, management, and morbidity of DKA. …