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ventilation may also be considered in order to support the patient’s efforts to achieve a
respiratory alkalosis. If intubated, the patient should be initially hyperventilated to the PCO 2
they were maintaining prior to the neurologic decompensation (generally 10 to 20 mm Hg in
the presence of severe ketoacidosis); this can be gradually reduced over several hours as the
acidosis resolves and the cerebral edema is treated.
Only after the patient is fully stabilized should a confirmatory computed tomography of the
head be considered, unless a diagnosis of intracerebral hemorrhage or thrombosis is strongly
suspected.
Clinical Indications for Discharge or Admission
Close monitoring is mandatory, and a well-organized flowsheet ensures all parameters are
being observed. Admission to an intensive care unit or specialized intermediate care unit
should be considered for DKA management. The patient should be maintained on continuous
cardiorespiratory monitoring with hourly assessments of blood pressure and level of
consciousness until the patient’s trajectory of illness has been clearly established. Careful
neurologic examination, with particular attention to level of cognition and pupillary reactivity,
should be performed frequently. The fluid input and output must be reviewed hourly to ensure
appropriate rehydration is occurring. The IV fluids should be checked frequently so that pump
failure or fluid leakage into the subcutaneous tissues can be corrected quickly. In the severely
ill child, an ECG should be performed in the setting of hyperkalemia or hypokalemia. The
plasma glucose should be measured hourly until the blood glucose is stable and less than 300
mg/dL, and as long as the child is on an insulin infusion. Glucose measurement may be less
frequent once the patient has been changed to subcutaneous insulin. Serum [K+ ] needs to be
measured every 2 to 4 hours until the acidosis and hyperglycemia are normalized, or more
frequently if hypokalemia is encountered or bicarbonate therapy is used. Calcium, phosphate,
and magnesium should be assessed initially and followed every 2 to 4 hours, more frequently
if any are being actively replaced. With the advent of point-of-care ketone measurements, it
may be advisable to follow serum ketone concentration every 2 to 4 hours, although
continuous noninvasive capnography with nasal cannula end-tidal CO2 (ETCO2 ) or
transcutaneous CO2 monitoring is also useful in tracking the degree of acidosis over time.
Venous pH may be obtained to follow resolution of the acidosis if the above monitoring
options are not available. Arterial sampling is not necessary for metabolic monitoring, and

central venous access is rarely necessary.
When the child is better hydrated and the acidosis resolves, mental alertness will improve
and symptoms of nausea, vomiting, and abdominal pain should remit. If they do not resolve,
an abdominal disorder should be considered. Some patients complain of blurred vision, which
is caused by lens distortion resulting from fluid shifts of rehydration and correction of
hyperglycemia—this should resolve within 24 hours of conclusion of therapy. When the anion
gap has closed, most patients are able to tolerate oral fluids, at which point rehydration can be
continued orally ad libitum.

MILD KETOACIDOSIS/HYPERGLYCEMIA
Goals of Treatment


To identify patients with hyperglycemia and/or mild ketoacidosis and initiate treatment per
algorithm.
To create a sick day plan for patients able to orally rehydrate, create sick day plan for them
upon discharge with close follow-up with their diabetes specialist.
CLINICAL PEARLS AND PITFALLS
Fasting laboratory plasma glucose of greater than 126 mg/dL or a random glucose
greater than 200 mg/dL on two separate occasions is diagnostic of diabetes in an
otherwise healthy person. This definition was developed by specialists in adult
diabetes and may not be completely applicable to the pediatric population.
Hyperglycemia in ED setting can result from numerous triggers including
intercurrent illness or trauma in patient with known DM, new-onset DM, other
illnesses associated with hyperglycemia, spurious blood sample, and medication
effect.
For purposes of definition, a patient with hyperglycemia does not have DKA if
venous pH is greater than 7.3 and serum bicarbonate is greater than 15 mEq/L.

Current Evidence

As noted in the previous section on diabetes and the following section on hypoglycemia,
glucose homeostasis reflects the balance between glucose input (from gut absorption, hepatic
glycogen breakdown, or gluconeogenesis) and disposal (via storage or oxidation). With the
exception of gut absorption, this process is largely regulated by insulin, although
counterregulatory hormones also have a significant effect. Furthermore, tissue factors and
medication also impact the insulin effect.

Clinical Considerations
Clinical Recognition
Plasma glucose concentrations in the 200 to 300 mg/dL range rarely result in symptoms. This
level of hyperglycemia may be accompanied by intermittent increased frequency of urination;
however, parents are rarely aware of their child’s frequency of urination once the child is toilet
trained unless the frequency becomes disruptive (e.g., nocturia or “accidents” at school).
Children and adolescents have no sense of what is the normal frequency of urination, so they
rarely complain unless the frequent urination is accompanied by dysuria. Higher levels of
glucose (greater than 300 mg/dL) may be associated with subtle clinical findings, such as
blurring of vision or dryness of oral membranes. Significant hyperglycemia may occur without
significant symptoms and can be tolerated for a prolonged period without clinical signs.
Triage
Generally, these patients are asymptomatic and very well appearing. Care must be taken to
distinguish from patients with more severe diabetic ketoacidosis and possible cerebral edema.
Initial Assessment/H&P


In the ED, hyperglycemia is likely to be seen in several different situations. First, the child
may be known to have diabetes and present with an intercurrent illness or traumatic injury.
Both illness and injury result in increased counterregulatory hormones, which may lead to
relative insulin resistance and hyperglycemia. The second presentation is the child for whom
diabetes is suspected because of classical symptoms of polyuria, polydipsia, and polyphagia
accompanied by weight loss. Almost half of children with new-onset diabetes mellitus present

to their pediatrician or to the ED in this way. Third, some medical conditions are associated
with persistent hyperglycemia, such as recurrent urinary tract infections and vaginal yeast
infections. Furthermore, type 2 diabetes is increasingly being reported in minority adolescents;
in many, hyperpigmentation of the posterior neck and axilla (acanthosis nigricans) may be
noted. Fourth, a laboratory panel obtained for some other reason (e.g., abdominal pain) may
reveal hyperglycemia.
If a child is severely ill and has concomitant hyperglycemia, close attention should be paid
to the underlying illness. Severity of hyperglycemia in the setting of critical illness is
correlated with mortality, and it can be thought of as a general index of illness severity in this
nondiabetes setting.
Management/Diagnostic Testing
Children who are mildly dehydrated (5%) with slight acidosis will benefit from an IV fluid
bolus (10 to 20 mL/kg of isotonic crystalloid); furthermore, this bolus may be given while
awaiting laboratory test results.
Insulin therapy can be initiated subcutaneously, at a total daily dose of 0.25 to 0.5
Unit/kg/day for the prepubertal child and 0.5 to 0.75 Unit/kg/day for the adolescent. Using the
basal-bolus approach, one-half of the total daily dose is administered as insulin glargine or
detemir, two 24-hour–acting analogs, and rapid-acting insulin (lispro, aspart) is dosed as a
combination of coverage for ingested carbohydrates and as a correction for the degree of
hyperglycemia above a chosen target—these initial dosages should be calculated along with
the help of a consulting diabetes specialist.
Hyperglycemia associated with critical illness, in a patient without diabetes, should be
managed in the context of the underlying illness. Specific therapy for hyperglycemia should
generally not be initiated in the ED, but can generally wait until the patient arrives in the ICU.
Clinical Indications for Discharge or Admission
Some children with new-onset diabetes may also have hyperglycemia without ketoacidosis or
with only mild acidosis. Generally, these patients are engaged in a 1- to 2-day program of
intensive diabetes education to teach the family and stabilize the insulin dosage; these
educational programs require multidisciplinary input from professional diabetes educators,
nutritionists, and social workers, and can take place in the inpatient or outpatient setting.

Children with known diabetes often develop hyperglycemia and ketosis without significant
acidosis (venous pH greater than 7.3 or bicarbonate greater than 15 mEq/L) during the course
of intercurrent illness, especially gastroenteritis, or secondary to omission of insulin doses.
Once the laboratory results are available, the physician must decide whether to hospitalize the
child, continue treatment in the ED, or send the child home. Several factors must be
considered before sending a child home.


1. Is the child fully conscious and alert?
2. Can the child drink and retain oral fluids?
3. Can home glucose monitoring be done and are all related supplies available in the home?
4. Can ketones be measured at home, either in the urine with chemical test strips or in the
serum with a point-of-care blood measurement device?
5. Will the child have competent supervision at home?
6. Does the family have access to both a telephone and transportation?
7. Is there a clinician available with whom the family can communicate by telephone?
8. Is the family comfortable with managing the mild acidosis at home?
If these questions can be answered in the affirmative, the child may be sent home.
Recommendations should be made to the family regarding fluid intake, insulin administration,
and monitoring. Specific recommendations may vary with the age of the child and the
experience of the family, but the following scheme may be helpful. Oral intake should be
about the same as would be given intravenously to resolve the deficit and provide maintenance
(e.g., the 10-year-old child [30 kg] would normally receive a 300-mL bolus followed by 100 to
140 mL/hr, for a total of up to 1 L during the first 6 hours intravenously if they were
hospitalized; therefore, the physician should suggest that the family try to get in 150 to 180 mL
of liquid every hour for the next 6 hours). It is best if this liquid is taken in as sips.
Supplements of short-acting insulin will be required in addition to the patient’s usual longacting doses. In the ED, two decisions will need to be made regarding insulin.
First, how much short-acting insulin (lispro or regular) should be given to the child before
discharge? One way to dose additional insulin is using the 5%–10% to 10%–15% rule.
If blood glucose is 250 to 400 mg/dL without urinary ketones, 5% of the child’s usual total

daily dose will suffice.
If blood glucose is more than 400 mg/dL without ketones, or is 250 to 400 mg/dL with
moderate or large ketones, 10% of the daily dose will be needed.
If blood glucose is more than 400 mg/dL and ketones are moderate or large, the child will
need 15% of the daily dose and admission to the hospital should be reconsidered.
Second, how much insulin should be given at home and with what frequency? Once home,
the preceding 5%–10% to 10%–15% rule is generally applicable and should be given every 4
hours, based on blood glucose and blood or urinary ketones. The family can begin using this
algorithm once the child is able to return to a normal intake. For any child to be safely
discharged home, however, he or she must be able to maintain adequate oral intake and have
frequent contact with a clinician who is comfortable managing pediatric diabetes. Finally,
hourly monitoring of blood glucose, urine output, and ketones is recommended with the
expectation that the blood glucose should decline, the urine output should fall, and the
ketones should begin to clear.
Failure to respond to these simple measures, whether in the ED or at home, should lead to a
consultation with the child’s endocrinologist. If oral fluids must be restricted and the child is
hyperglycemic (e.g., a child with traumatic injury requiring surgery), IV fluids without glucose
should be used and glucose should be monitored frequently. As blood glucose concentration
reaches 200 mg/dL, dextrose should be added to the IV fluid to maintain target blood glucose