Pediatric
Hyperglycemia and
Diabetic Ketoacidosis
(DKA)
5th Edition, 2019
1
Illinois EMSC is a collaborative program between the Illinois Department of Public
Health and the Ann & Robert H. Lurie Children’s Hospital of Chicago. Revision of
this presentation was supported in part by: Grant 6 H33 MC 31621 from the
Department of Health and Human Services Administration, Maternal and Child
Health Bureau
Today, almost a century after the discovery of insulin,
the most common cause of death in a child with
diabetes, from a global perspective, is lack of access
to insulin or improper use of insulin.
Many children die even before their diabetes is
diagnosed. Around the world, forces have united to
make it come true that no child should die from
diabetes or its complications.
2
Illinois Emergency Medical
Services for Children (EMSC)
Illinois EMSC is a collaborative program between the
Illinois Department of Public Health and Lurie
Children’s Hospital of Chicago, aimed at improving
pediatric emergency care within our state.
Since 1994, Illinois EMSC has worked to enhance
and integrate:
• Pediatric education
• Practice standards
• Injury prevention
• Data initiatives
This educational activity is
being presented without
the provision of commercial
support and without bias or
conflict of interest from the
planners and presenters.
3
http://www.idph.state.il.us/
http://loyolamedicine.org/
http://www.luhs.org/depts/emsc/index.htm
Define and explain pediatric hyperglycemia and DKA
Highlight current standards of care regarding pediatric
hyperglycemia and DKA management
Provide educational resources to health care
professionals to share with pediatric patients and
families dealing with issues related to pediatric
hyperglycemia and DKA
Goals
4
Suggested Citation: Illinois Emergency Medical Services for Children (EMSC), Pediatric Hyperglycemia and DKA, December 2018
5
EMSC Facility Recognition & Quality Improvement Committee
Acknowledgements
The Illinois EMSC Advisory Board gratefully acknowledges the commitment and
dedication of the EMSC Facility Recognition & Quality Improvement Committee in
revising this educational module (which was originally published in October 2012).
Their contributions have led to this valuable resource and assists Illinois EMSC in
striving toward the goal of improving pediatric emergency care within our state.
To access a list of the committee members, click here.
http://ilemsc.org/dka/EMSC_Fac_Rec_and_QI_Committee_DKA.pdf
Table of Contents
Introduction
Assessment
Management
Complications
Patient Education
Resources
Test Your Knowledge
References
Appendices
Appendix A: Assessment Tools
Appendix B: “Two-bag System”
Appendix C: Treatment Guidelines
6
INTRODUCTION
Return to Table of Contents
7
Purpose
The purpose of this educational module is to enhance the care
of pediatric patients who present with hyperglycemia and
diabetic ketoacidosis (DKA) through appropriate:
ASSESSMENT
MANAGEMENT
PREVENTION OF COMPLICATIONS
DISPOSITION
PATIENT & PARENT/CAREGIVER EDUCATION
8
Objectives
At the end of this module you will be able to:
Describe the mechanisms of hyperglycemia and DKA
Perform an initial assessment on a child who is experiencing
hyperglycemia and DKA
Describe the clinical presentation of a pediatric patient with DKA
Understand the physiologic changes taking place in a pediatric
patient with DKA
Develop an effective management plan
Discuss cerebral edema as a complication of pediatric DKA
Develop a plan for appropriate admission, transfer or referral
Formulate appropriate discharge instructions
9
The following publications were the primary sources of
information for this module, and will be referenced throughout:
The American Diabetes Association (ADA)1
Diabetic Ketoacidosis in Infants, Children, and Adolescents
A consensus statement from the American Diabetes Association
European Society for Paediatric Endocrinology (ESPE)2
Lawson Wilkins Pediatric Endocrine Society (LWPES)2
European Society for Paediatric Endocrinology / Lawson Wilkins Pediatric
Endocrine Society Consensus Statement on Diabetic Ketoacidosis in Children
and Adolescents
International Society for Pediatric and Adolescent Diabetes (ISPAD)3
Diabetic Ketoacidosis in Children and Adolescents with Diabetes
ISPAD Clinical Practice Consensus Guidelines 2009 Compendium
Main Resources
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Frequency of DKA
DKA occurs in children with:
New-onset of type 1 diabetes mellitus
Established type 1 diabetes mellitus during risk episodes
May occur in children with type 2 diabetes mellitus
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DKA Risk Factors
Young children
Poor diabetes control
Previous episodes of DKA
Missed insulin injections
Insulin pump failure
Infection or other illnesses
Low socioeconomic status
Lack of adequate health insurance
Psychiatric disorders (i.e., eating disorders)
12
Illinois EMSC Statewide DKA QI
DKA record review (532 records total) - high percentage of cases
reported documentation of: full set of vital signs, blood glucose level,
and neurological status during initial assessment
However, documentation of ongoing/hourly ED monitoring for same
indicators was much less consistent
Percentage of documentation even lower for hospitals that (on survey)
reported ED ongoing monitoring was “not defined in policy” or performed “per
physician decision”
93%
70%
93%
58%
52%
37%
0%
20%
40%
60%
80%
100%
Vital Signs Blood Glucose Neurological Assessment
ED Monitoring of Pediatric DKA Patients (532 records)
Initial Hourly
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Practice Deviations
(within 1st hour of treatment)
Guideline Recommendations
Administer an IV fluid bolus 15-20
mL/kg 0.45% NaCl over the first
hour
The recommended fluid course is 10-20
mL/kg 0.9% NaCl over the first hour
Administer an IV insulin drip of
0.1 units/kg/hour
Current guidelines recommend administering
insulin after the initial fluid resuscitation, not
concurrently
Administer an IV insulin bolus of
0.1 units/kg
Current guidelines suggest IV insulin bolus
may increase the risk of cerebral edema, and
should not be used at the start of therapy
Wait for more laboratory results
before giving any fluids
Current guidelines recommend initial IV fluid
administration should begin immediately
Illinois EMSC Statewide DKA QI
** Additional findings from the statewide QI project (responses to survey and case
scenarios) seem to indicate concerning deviations from the current treatment
guidelines for pediatric DKA patients within the first hour of treatment**
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Understanding Diabetes
Diabetes mellitus, often referred to simply as diabetes.
Diabetes is a condition in which the body:
Does not produce enough insulin, and/or
Does not properly respond to insulin
Insulin is a hormone produced in the pancreas. Insulin enables
cells to absorb glucose in order to turn it into energy.
15
The cause of diabetes in children continues to be a mystery.
Genetics
Environmental factors
Obesity
Lack of exercise
Diabetes: An Epidemic
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Type 1 vs. Type 2
Type 1 diabetes Type 2 diabetes
Diagnosed in children
and young adults
Typically diagnosed in
adulthood
Previously known as
Juvenile Diabetes
Also found in overweight
children
Insulin-dependent Non-insulin-dependent
Body does not produce
insulin
Body fails to produce
and properly use insulin
17
Diabetes: Warning Signs
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Complications of blood glucose alterations
Hypoglycemia
Hyperglycemia
Ketosis
Acidosis
DKA (Hyperglycemia + Ketosis + Acidosis)
Blood Glucose Alterations
Normal fasting blood glucose level 80 - 120 mg/dL
19
Hypoglycemia
Low blood glucose: treated when less than 70 mg/dL4
Develops because the body doesn’t have enough glucose to
burn energy
Can happen suddenly
Can be treated quickly and easily by eating or drinking a small
amount of glucose rich food
The signs and symptoms include:
Low blood glucose
Hunger
Headache
Confusion, shakiness, dizziness
Sweating
If h
