Abstract
DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.
Highlights
Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes mellitus (DM) and consists of the biochemical triad of hyperglycemia, ketonemia, and metabolic acidosis [1]
There are few pediatric intensive care unit (ICU) beds in public hospitals, which are usually occupied by children who demand ventilatory support; most of DKA patients will be managed in general emergency wards
We report here a local experience with an alternative fluid and insulin therapy protocol designed to abbreviate the time on intravenous infusion line for the management of uncomplicated DKA cases in a Brazilian pediatric emergency department
Summary
Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes mellitus (DM) and consists of the biochemical triad of hyperglycemia, ketonemia, and metabolic acidosis [1]. According to this alternative insulin therapy protocol, SC rapid-acting analog is initiated at a dose of 0.15 U/ kg every 2 hours, reducing it to 0.1 U/kg in case the rate of falling of plasma glucose concentrations exceeds 100 mg/dl/hour, until resolution of metabolic acidosis [30,32]. 12 hours after the treatment beginning, when metabolic acidosis is usually under control, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day This higher dose is required to compensate for the insulin resistance determined by DKA, and it will be frequently associated with extra SC 0.1 U/kg doses of rapid-acting analog according to capillary blood glucose monitoring every 3 hours. The use of elevated volumes of saline solution (0.9% sodium chloride) could be associated with
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