Application of bench studies at the bedside to improve outcomes in the management of severe diabetic ketoacidosis in children—a narrative review

Abstract

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. Background:The classic triad of DKA namely hyperglycemia, metabolic acidosis and ketonemia warrants immediate attention with fluids and insulin. Correction of dehydration in DKA is of utmost priority and the calculation of fluid volume and choice of fluid have remained a matter of debate. Insulin therapy, to halt the ketone production, in DKA has undergone wide variations in dose and preparation since its discovery.Although the mortality due to severe DKA has remarkably decreased, complications like cerebral edema and acute kidney injury (AKI) continue to haunt the intensivists and endocrinologists on a few occasions.Methods: We have selected a few important questions in the management of severe DKA in children, addressing the challenges, reviewing the studies, guidelines and bedside practices with evidence in this narrative review. Conclusions:The focus of management should be to understand and normalise the deranged physiology rather than trying to get normal laboratory reports. This needs careful understanding of the pathogenesis and deriving conclusion from bench studies. With newer studies and evidence, guidelines are revised every few years. There is a trend towards more conservative therapy, with continuous and advanced monitoring.Switching to subcutaneous insulin and oral hydration is done as early as possible with clinical monitoring and resolution of DKA. Management of severe DKA in children can vary from simple fluid titration and insulin infusion in mild cases to a scenario with multiorgan dysfunction requiring intensive monitoring and advanced organ support. Individualisation of therapy to suit the needs with the available evidence and expertise is extremely essential.

Liječenje dijabetičke ketoacidoze u djece i adolescenata

“…Preporuka ranijih smjernica bila je da se prije kontinuirane infuzije brzodjelujućeg inzulina primijeni bolus-doza inzulina, međutim istraživanja su utvrdila da bolus-doza inzulina pridonosi razvoju edema mozga, naglom padu osmotskog tlaka i može pogoršati hipokalijemiju 3,25 . Kada je pH > 7,30, bikarbonati > 15 mmol/L, betahidroksimaslačna kiselina < 1 mmol/L, odnosno anionski zjap < 12 mmol/L, može se započeti supkutana primjena inzulina.…”

Intravenous Insulin Infusion Rate and Its Impact on the Time to Resolution of Diabetic Ketoacidosis

“…ДКАтяжелое осложнение СД 1 типа, которое возникает при недостатке инсулина в организме, что приводит к повышению уровня глюкозы в крови и выработке кетонов [5][6][7]. В основе ДКА лежит классическая триада: гипергликемия, кетонемия и метаболический ацидоз [8]. Симптомы ДКА в детском и подростковом возрасте включают: полиурию, полидипсию, тошноту и рвоту, боль в животе, одышку, тахикардию и нарушение уровня сознания [1].…”

"Diabetic Ketoacidosis: Precipitating Factors, Pathophysiology, and Management"

“…The severity of DKA is determined by the degree of acidosis such as mild; when venous pH >7.2 and <7.3, bicarbonate <10 mmol/L; severe when venous pH <7.1, bicarbonate <5 mmol/L [5]. Diabetic ketoacidosis is a life threatening emergency manifesting with hyperglycemia when random blood sugar >200 mg/dL, high anion gap metabolic acidosis (pH-3) [6].…”