Diabetic ketoacidosis

In this review, we address a few key issues and the challenges faced in the management of severe diabetic ketoacidosis (DKA) in children, highlighting the existing standard of care, supported by evidence and bench studies.

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus. Careful and timely intervention is required to optimise glycaemic control and reduce the risk of mortality and devastating complications. Of these, cerebral oedema is the leading cause of death, with a mortality rate of approximately 25%. This article highlights the recent updates to UK fluid therapy guidelines for DKA and provides clinical context for the benefit of paediatricians and junior doctors in light of this new guidance.

To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA. DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [ 60 years old], male gender, BMI 30, blood glucose level > 1000 mg/dl, and anion gap 30 mEq/l.

To determine if diabetes awareness campaigns are an effective intervention to reduce diabetes ketoacidosis at diagnosis of type 1 diabetes in children and youth. This review demonstrated that DKA awareness campaigns are effective to reduce DKA among children and adolescents with type 1 diabetes and the core components that explain why these campaigns are effective.

Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.

Previous research has indicated that rapid rehydration in children with type 1 diabetes who present with diabetic ketoacidosis could result in cerebral edema. I have been treating patients with diabetic ketoacidosis with gradual fluid replacement. With the risk of cerebral injury in these patients, should I continue management with slow fluid rehydration?

The optimal fluid treatment protocol for children with diabetic ketoacidosis (DKA) has long been a subject of controversy. Until recently, there was no high-quality evidence from randomized clinical trials to support an optimal guideline, and recommendations were mainly based on theoretical considerations. As a consequence, fluid treatment protocols for children with DKA vary between institutions (and countries). In June 2018, the results from the Fluid Therapies Under Investigation in DKA Trial conducted in the Pediatric Emergency Care Applied Research Network were published. This large, factorial-designed randomized controlled trial assessed neurological outcomes of 1387 children with DKA who were treated with one of four fluid protocols that varied in infusion rate and sodium content. In this commentary, we review and discuss the results of this new study and the implications for clinical care of DKA in children.

Objective: This study was designed to examine the efficacy and risk of bicarbonate administration in the emergent treatment of severe acidemia in diabetic ketoacidosis (DKA).

Objective: To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.