Diabetic ketoacidosis in children: review of pathophysiology and treatment with the use of the

Abstract

Objectives: To review diabetic ketoacidosis, including the two bags system, a method of administering liquids in order to provide a smoother correction of the hyperglycemic and ketotic states.Methods: Review of recent publications (last 7 years) from a Medline search and chapters published in pediatric textbooks that discuss the etiology, therapy, and complications of diabetic ketoacidosis. The management approach incorporates the findings of these publications as well as the clinical experience at the Childrens Hospital of Philadelphia and Duke University Medical Center. Results:The pathology of the type 1 Diabetes Mellitus involves the progressive destruction of the ß cells of the pancreas, causing insulin deficiency. Insulin is essential in the metabolism of carbohydrates, protein and fat. Insulin deficiency may lead to diabetic ketoacidosis which has three components: 1) hyperglycemia, which causes glycosuria and consequently dehydration; 2) lipolysis which, causes ketonemia/ketonuria; and 3) acidosis, that is caused by the dehydration and the high serum levels of ketones. Diabetic ketoacidosis is a serious condition and, if not treated appropriately, can cause coma and death. In children cerebral edema is the major complication of the therapy for diabetic ketoacidosis. Careful replacement of insulin, fluids, glucose and electrolytes is essential. Conclusions:The literature presents different ways to manage DKA in pediatrics, without a consensus on the cause of the most important complication (cerebral edema), and consequently without a consensus on the best approach.The use of the two saline bags in patients in DKA allows fast adjustments in the dextrose concentration of the infusion fluids, simplifying and reducing the costs of the treatment of diabetic ketoacidosis.J Pediatr (Rio J) 2001; 77(1): 9-16: diabetes mellitus, cerebral edema, diabetic ketoacidosis, fluid therapy. ResumoObjetivo: Rever vários aspectos da cetoacidose diabética, incluindo o sistema de duas soluções, um método de administrar líquidos que proporciona correção mais suave do estado de hiperglicemia e de cetose.Métodos: Revisão de publicações recentes (dos últimos 7 anos) referidas na base de dados da Medline e capítulos de livros de pediatria que abordam a etiologia, o tratamento e as complicações da cetoacidose diabética. O tratamento aqui apresentado utiliza a informação encontrada nestes artigos e a experiência clínica adquirida no Childrens Hospital of Philadelphia e no Duke University Medical Center.Resultados: A patologia do diabetes mellitus tipo 1 envolve a destruição das células ß do pâncreas, causando uma deficiência de insulina. A insulina é essencial para o metabolismo de carboidratos, proteínas e gorduras. A deficiência de insulina pode levar a um quadro de cetoacidose diabética que apresenta três componentes: 1) a hiperglicemia, que causa glicosúria e conseqüentemente desidratação; 2) a lipólise em excesso, que causa aumento nos níveis séricos e urinários de corpos cetônicos; e 3) a acidose metabólica, que é causa...

Comparison of a ‘two-bag system’ versus conventional treatment protocol (‘one-bag system’) in the management of diabetic ketoacidosis

“…As opposed to the conventional protocol (one-bag system), the two-bag system uses two bags of fluids with identical electrolyte content but different dextrose concentrations, 0% and 10%. 20 21 The two bags are connected in a ‘Y’ fashion and by adjusting the infusion rates from each bag, the concentration of dextrose can be customized to prevent unpredictable excursions in blood glucose. The two-bag system has been more commonly used and exclusively studied in the pediatric population and has been found to be cost effective.…”

Pathophysiological Mechanisms of Cerebral Edema in Diabetic Ketoacidosis in Pediatric Practice

“…Патофизиология ОГМ в ходе ДКА у детей и подростков еще не конца понятна и плохо изучена [7,13,14,25,43,45,46]. На сегодняшний день существуют три важных патофизиологических звена в развитии ОГМ на фоне ДКА [3,12,15,28,29,38,43,48]:…”

“…По другим источникам [42], ОГМ при ДКА чаще всего возникает у детей в течение первых 12 часов после начала интенсивной терапии и редко возникает до начала лечения или в конце лечения. К другим факторам риска ОГМ у детей на фоне ДКА относят: исходный pH<7,1, сопутствующую психическую патологию, быструю регидратацию (>50 см 2 первые 4 ч), резкое снижение гликемии (более 3 ммоль/час) при в/в введении инсулина [7,35]. Однако доказательства того, что ОГМ при ДКА у детей является в первую очередь ятрогенным состоянием, не являются убедительными [13,20,27].…”

Managment of diabetic ketoacidosis in children and adolescents in sub-Saharan Africa: A review

“…DKA is generally categorised by the severity of the acidosis, varying from mild DKA (venous pH: <7.30 and/or bicarbonate concentration <15 mmol/ L), moderate DKA (pH: <7.2 and/or bicarbonate: <10mmol/L) to severe DKA (pH: <7.1, and/or bicarbonate: <5 mmol/L) (2,20).…”

“…Definition of DKA includes hyperglycaemia (blood glucose > 11 mmol/ L [~200 mg/dL]), venous pH <7.3 or bicarbonate <15 mmol/L, in association with ketonemia, ketonuria and glycosuria; occasionally some patients present with normal glycaemic ketoacidosis (2). A decrease in serum insulin and a glucoregulatory hormones imbalance, causing hyperglycaemia, lipolysis and acidosis, are responsible for developing DKA (1).…”