Diabetic ketoacidosis and hyperglycemic hyperosmolar state

This article is a chapter in the ISPAD Clinical Practice Consensus Guidelines 2014 Compendium.The complete set of guidelines can be found for free download at www.ispad.org.The evidence grading system used in the ISPAD Guidelines is the same as that used by the American Diabetes Association.See page 3 (the Introduction in Pediatric Diabetes 2014; 15 (Suppl.20): 1-3). Diabetic ketoacidosis and hyperglycemic hyperosmolar stateRisk factors for DKA in patients with known diabetes include insulin omission, poor metabolic control, previous episodes of DKA, gastroenteritis with persistent vomiting and inability to maintain hydration, psychiatric (including eating) disorders, challenging social and family circumstances, peripubertal and adolescent girls, limited access to medical services, failures in insulin pump therapy.The following recommendations are based on currently available evidence and are intended only as a general guide to DKA management.Because there is considerable individual variability in presentation of DKA (ranging from mild with only minimal dehydration to severe with profound dehydration), some patients may require specific treatment that, in the judgment of the treating physician, may be within or, occasionally, outside the range of options presented here.Clinical judgment should always be used to determine optimal treatment of the individual patient, and timely adjustments to treatment (insulin dose, electrolyte composition and rate of infusion of rehydration fluids) should be based on ongoing, careful clinical and biochemical monitoring of the patient's response.Emergency assessment should follow the general guidelines for Pediatric Advanced Life Support (PALS) and includes: immediate measurement of BG, blood or urine ketones, serum electrolytes, blood gases and full blood count; assessment of severity of dehydration and level of consciousness (E).A second peripheral IV catheter should be inserted (E).Management should be in centers experienced in the treatment of DKA in children and adolescents and where vital signs, neurological status and laboratory results can be monitored frequently (E).Where geographic constraints require that management be initiated in a center with less experience and with fewer resources, there should be arrangements in place for telephone or videoconference support from a physician with expertise in DKA (E).Meticulous monitoring of the clinical and biochemical response to treatment is necessary so that timely adjustments in treatment can be made when indicated by the patient's clinical or laboratory data (E).Goals of therapy are to correct dehydration, correct acidosis and reverse ketosis, slowly correct hyperosmolality and restore BG to near normal, monitor for complications of DKA and its treatment, and identify and treat any precipitating event.Fluid replacement should begin before starting insulin therapy.Expand volume, as required, to restore peripheral circulation (E).Calculate the subsequent rate of fluid administration, including the provision of maintenance fluid requirements, aiming to replace the estimated fluid deficit evenly over 48 h.The rate of fluid administration should