2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S152 through earlier recognition and initiation of insulin therapy. Public awareness campaigns about the early signs of diabetes have significantly reduced the frequency of DKA in new-onset diabetes (33). In children with established diabetes, DKA results from failing to take insulin or poor sick-day management. Risk is increased in children with poor metabolic control or previous episodes of DKA, peripubertal and adolescent girls, children with psychiatric disorders and those with difficult family circumstances (34). The frequency of DKA in established diabetes can be decreased with education and family support (35) as well as access to 24-hour telephone services for parents of children with diabetes (36,37). Management of DKA While most cases of DKA are corrected without event, 0.7 to 3.0% of pediatric cases are complicated by cerebral edema (CE) (38), which is associated with significant morbidity (21 to 35%) and mortality (21 to 24%) (39). In contrast, CE has rarely been reported in adults (34,39).Although the cause of CE is still unknown, several factors are associated with increased risk (Table 2) (40-43). A bolus of insulin prior to infusion is not recommended (44) since it does not offer any faster resolution of acidosis (45,46) and may contribute to CE (47). Recent evidence suggests early insulin administration (within the first hour of fluid replacement) may increase the risk for CE (48). Special caution should be exercised in young children with DKA and new-onset diabetes or a greater degree of acidosis and extracellular fluid volume (ECFV) depletion because of the increased risk of CE. Use of bedside criteria may allow earlier identification of patients who require treatment for CE (49). DKA should be managed according to published protocols for management of pediatric DKA (50) (Figure 1). IMMUNIZATION Historically, national guidelines have recommended influenza and pneumococcal immunization for children with type 1 diabetes (51-53). Currently, there is no evidence supporting increased morbidity or mortality from influenza or pneumococcus in children with type 1 diabetes (54,55). However, Table 2. Risks factors for CE • Younger age (
Figure 1. Immediate assessment and management of DKA in children Clinical history • Polyuria • Polydipsia • Weight loss (weigh) • Abdominal pain • Tiredness • Vomiting • Confusion • Shock (reduced peripheral pulses) • Reduced consciousness or coma Resuscitation • Airway ± nasogastric tube • Breathing (100% O2) • Circulation (0.9% NaCl 10–20 mL/kg over 1–2 h), and repeat until circulation is restored), but do not exceed 30 mL/kg Acidosis not improving Re-evaluation • IV fluid calculations • Insulin delivery system and dose • Need for additional resuscitation • Consider sepsis BG = blood glucose DKA = diabetic ketoacidosis Adapted with permission from Reference 50. ECG = electrocardiogram ICU = intensive care unit Immediate assessment Clinical signs • Dehydration (assess) • Deep sighing respiration (Kussmaul) • Smell of ketones • Lethargy/drowsiness ± vomiting Diagnosis of DKA confirmed Contact senior staff • Dehydration >5% • Not in shock • Acidotic (hyperventilation) • Vomiting IV therapy • Calculate fluid requirements • Correct over 48 hours • 0.9% NaCl • ECG for abnormal T-waves • Add 40 mmol/L KCl Continuous IV insulin infusion 0.1 U/kg/h to be started 1–2 hours after IV rehydration initiated • Hourly BG • Hourly fluid input and output • Neurologic status at least hourly Critical observations PG 14.0–17.0 mmol/L; or PG falling >5.0 mmol/L/h • Electrolytes every 2 h after start of IV therapy • Monitor ECG for T-wave changes IV therapy • Change to 0.45% NaCl + 5% glucose • Adjust [Na + ] infusion to promote an increase in measured serum [Na + ] Improvement • Clinically well • Tolerating oral fluids Transition to SC insulin Start SC insulin then stop IV insulin after an appropriate interval IV = intravenous PG = plasma glucose Biochemical features and investigations • Ketones in urine • Elevated BG • Acidemia • Blood gases, urea, electrolytes • Other investigations as indicated • Minimal dehydration • Tolerating oral fluid Therapy • Start with SC insulin • Continue oral hydration No improvement Neurological deterioration (Warning signs: headache, slowing heart rate, irritability, decreased level of consciousness, incontinence, specific neurological signs) Exclude hypoglycemia Is it cerebral edema? Management • Give mannitol 0.5–1 g/kg • Restrict IV fluids by one-third • Call senior staff • Move to ICU • Consider cranial imaging only after patient stabilized SC = subcutaneous S153 DIABETES IN CHILDREN AND ADOLESCENTS
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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