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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 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 to 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 to 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 to 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 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 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? Can the child drink and retain oral fluids? Can home glucose monitoring be done and are all related supplies available in the home? 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? Will the child have competent supervision at home? Does the family have access to both a telephone and transportation? Is there a clinician available with whom the family can communicate by telephone? 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 L during the first 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 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 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 ... 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... 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... 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