Clinical aspects of diabetic ketoacidosis

ISPAD Clinical Practice Consensus Guidelines 2018: Sick day management in children and adolescents with diabetes

“…Some illnesses, especially those associated with fever, raise blood glucose levels because of higher levels of stress hormones promoting glycogenolysis, gluconeogenesis, and insulin resistance . Illness often increases ketone body production due to inadequate insulin levels and the counter‐regulatory hormone response.…”

“…The insulin dose may need to be increased or decreased to maintain glucose metabolism but it should never be stopped (see Table for insulin dosing recommendations). The most common mistake made by health care providers and caregivers who are unfamiliar with diabetes is to recommend the complete omission of insulin because “the child is ill and not eating,” thus increasing the risk of frank DKA Even in the fasting state, some insulin is required for basal metabolic needs, which may go up during an acute illness, when counter‐regulatory stress hormones are elevated, so that more frequent monitoring of blood glucose and ketones is required to direct insulin dosing. If episodes of hyperglycemia, ketosis, and vomiting recur, with or without infection, it should be recognized that this may be due to insulin restriction or omission .…”

“…Family dysfunction or a psychiatric illness in a caregiver is frequently seen in such circumstances, and may contribute to the recurrence of DKA episodes either directly or indirectly . Lack of appropriate adult supervision needs to be considered, with appropriate therapeutic interventions put into place, since recurrent DKA has a high association with DKA‐related complications, including coma and death …”

“… Hyperglycemia, fever, excessive glycosuria, and ketonuria all contribute to increased fluid losses. Sick day cabinets should contain supplies as above to prevent dehydration. Liquids for hydration should contain salt and water and not just plain water, especially if there are ongoing losses associated with vomiting or diarrhea. Chicken soup, consommé, home‐made lemonade with both salt and sugar, or clear broths, are excellent sources of water and electrolytes, which may be needed to maintain hydration and to avoid water and electrolyte imbalance in conditions leading up to DKA . If appetite is decreased or the glucose level is falling below 10 mmol/L (180 mg/dL), sugar‐containing fluids should be considered to decrease risk of starvation ketosis, along with insulin at an adjusted dose.…”

“…Elevated levels of ketones, whether associated with hypoglycemia (starvation ketosis) or hyperglycemia and insulin deficiency, can contribute to nausea and may lead to decreased food and fluid intake, exacerbating dehydration and ketosis, increasing the risk for DKA. Intravenous fluids may be required if nausea, vomiting, or diarrhea are persistent with ongoing weight loss, especially in young children who are at great risk for dehydration without adequate enteral intake.…”