Diabetic ketoacidosis (DKA) - a state of absolute insulin deficiency, accompanied by an increased level of kontrregulyatornyh hormones (primarily, glucagon and catecholamines and cortisol, and growth hormone).DKA can occur in children with newly diagnosed diabetes, as well as have long been suffering from diabetes in the case of infection or skip insulin injections.In adolescents, the DFA can be triggered by a violation of the diet, and excessive alcohol consumption.DFA - a serious condition, which is still the leading cause of death for children with diabetes.Therefore, treatment of DKA should be carried out in pediatric centers specialized in the field of childhood diabetes.
Verification of the diagnosis of DKA is based on the clinical condition of the child, the presence of hyperglycemia (& gt; 13 mmol / L), moderate or severe ketonuria or ketonemia and the level of plasma bicarbonate less than 22 mmol / L.
Depending on the level of plasma bicarbonate usually allocate 3 severity
• Mild - 16 bicarbonate 22 mmol / l
• Medium degree - bicarbonate 10-16 mmol / l
• Severe - bicarbonate & lt;10 mmol / l
In each case, the DFA is necessary to identify and treat potential precipitating factor (infection).Once diagnosed with DKA, it is necessary to begin treatment and carefully monitor the condition of the child.
on admission should be evaluated the following parameters:
• Clinical status and degree of dehydration
• Body weight
• Blood pressure
• Body temperature
• Blood glucose,Urea plasma potassium, sodium, blood gases, pH, and levels of ketone bodies in urine
• Blood cultures, chest X-ray, crop of the throat, or urinalysis, according to testimony
Blood pressure, pulse, respiratory rate, blood glucoseWe should be monitored hourly.Blood electrolyte levels should be measured every 3-4 hours prior to stabilization.All the urine should be tested for ketones until negative indicators.
DKA treatment the child should be started immediately.The most important component of treatment is fluid, insulin, electrolytes.Venous access should be provided immediately after admission to the hospital.If the child is in a state of shock (hypotension, decreased peripheral circulation, precoma), urgent measures have to start with bolus administration of 0.9% NaCl isotonic solution of 10-15 ml / kg with 5% solution of human albumin.The introduction of these solutions is repeated until normalization of hemodynamics.
• If pulmonary ventilation is inadequate, it is necessary to discuss the need for an auxiliary or artificial pulmonary ventilation
• If the child is unconscious or has a place of repeated vomiting, necessary to introduce a nasogastric tube
• If the child is unconscious and palpable enlargedbladder, or the child does not urinate for 3-4 hours required bladder catheterization
DFA is always accompanied by a marked shortage of potassium.Sodium levels may be normal or low due to the dilution effect resulting from hyperglycemia.During the correction of severe hyperglycemia sodium levels should rise by 1.6 mmol / L for every 5.6 mmol / L reduction in blood glucose.
Children with severe DKA often lose 10-15% of initial body weight, and can thus be significantly dehydrated.It is therefore extremely important therapeutic measure is timely replacement of fluids.It should be carefully monitored, especially in young children, because for them, even a small amount can make a significant percentage of the total amount of fluid in the body.In this connection the balance accurate estimate of fluid dynamics, to be carried out at intervals of several hours.The volume of fluid injected is based on the degree of dehydration and physiological needs of the child.Patients with mild DKA usually fluid loss is compensated through the mouth, and insulin therapy is conducted in the form of subcutaneous injections.However, in the case of DKA moderate and severe, IV fluids and insulin should be administered intravenously.Because of the risk of volume overload and the occurrence of cerebral edema administering fluids within the first 24-36 hours should be made cautiously.
fluid delivery results in a reduction in blood glucose, even without insulin, and blood glucose level of about 12 mmol / L intravenous saline solution must be replaced by 5-10% glucose solution.Because of the risk of overhydration maximum quantity of fluid administered during the first 24 hours must not exceed 4 l / m.
Low doses of short-acting insulin should be administered intravenously either as a continuous infusion or bolus hourly.Insulin can not be mixed with the injected fluid, and administered separately from the rate of 0.1 IU. / Kg / hr.The aim is to reduce the blood glucose is not more than 4-5 mmol / l per hour, as a more rapid reduction entails the development of cerebral edema.Due to the fact that the correction of acidosis takes longer than the correction of hyperglycemia, treatment should continue until normalization of plasma bicarbonate.At this time, the liquid insulin and must be administered in a ratio of compatible blood glucose in the range of 5-15 mmol / l.After correction of acidosis and the normalization of the patient's condition can allow the patient meal.And to make the first injection of insulin subcutaneously 30 minutes before the meal (injected short-acting insulin or a mixture of insulin of short and medium duration).Intravenous infusion of insulin should be phased out within the next hour.Later it can be any of the aforementioned modes of insulin therapy.
DFA is always accompanied by a marked shortage of potassium, even when the level of potassium in the plasma of normal or even elevated.In this regard, intravenous potassium compensation should be started immediately.First, add 20 mM KCl for each 500 ml of liquid, and then adjust the amount of potassium administered depending on the level of plasma potassium.
If, despite the introduction of potassium, severe hypokalemia is stored (& lt; 2.8 mmol / l), the dose of insulin should be reduced to 0.05 u / kg / h.
measured serum sodium is usually low due to the dilution effect resulting from hyperglycemia.The true level of sodium can be calculated using the following formula:
true sodium serum sodium x = [1.6 x (blood glucose - 5.5) / 5.5] mmol / l
correction of hyponatremia usually is not required.However, if the true figures sodium below 160 mmol / l or below 120 mmol / l, then we can talk about the hyper / hyponatremia.To prevent the development of cerebral edema needed careful assessment of the amount of fluids administered and slower rehydration period (48-72 hours).
introduction of bicarbonates in the DFA is controversial and is generally not recommended.In children with severe DKA (at pH & lt; 7.0) cautious introduction of hydrogen is possible.
recommended doses of sodium bicarbonate (167 mmol / l) is 1-2 mmol / kg.Half of the dose must be administered slowly over 30 minutes and the other half - during the next 1-2 hours.Introduction of the sodium bicarbonate may be repeated at intervals of 3-4 hours, until the pH was above 7.1.Possible risk of treatment with sodium bicarbonate in the DFA is to enhance hypokalemia, paradoxical acidosis build-up in the CNS and the development of cerebral edema.Introduction bicarbonate should be administered concurrently with the administration of sodium chloride (as shown in table above).
DKA metabolic complications such as hypoglycemia, hypokalemia and hypernatremia, can be avoided with the proper administration of fluids and insulin.The most severe and dangerous complication of DKA is cerebral edema, leading to wedging of the brain stem and cerebellum in the big hole skull.Etiology and pathogenesis of cerebral edema are poorly understood, but the most likely cause is too fast correction of deficit and liquids tiperglikemii.In recent years, computer tomography has been shown that subclinical brain swelling occurs in many children with DFA, but clinically significant cerebral edema develops only some.
Symptoms of cerebral edema include headache, disturbance of consciousness, slow heart rate and high blood pressure, which appear and grow very quickly.Currently, conventional treatment recommendations of cerebral edema is not, however, limit the introduction of fluids, ventilation, mannitol infusion of 1-2 g / kg for 20 minutes LP can reduce intracranial pressure.The prognosis of cerebral edema is poor, and every effort should be to its prevention.
In each case, the DFA is necessary to identify the cause and fix it if possible.Inadequate training of the patient and his family often underlies the DFA.It is therefore important to assess the ideas and knowledge of the child and his family about diabetes and, if necessary, repeat the course.