Diabetic Ketoacidosis (DKA) is a serious condition that can be life threatening. It most commonly occurs when a diagnosis of Type 1 diabetes is first made. It can occur when a person with known Type 1 diabetes becomes unwell or has very high blood glucose levels (BGLs) resulting from a lack of insulin. It can even occur in the presence of normal glucose levels in children and young people with known diabetes.

Type 1 diabetes is the most common form of diabetes affecting children and adolescents in Australia. The condition occurs when the body does not have enough insulin (a hormone which helps glucose move from the blood into the cells). Insulin is also responsible for controlling the level of glucose in the blood. Without insulin, glucose levels will build up in the blood. Type 1 diabetes is treated by replacing the body’s missing insulin, with injectable insulin.

Some of the signs and symptoms of Type 1 diabetes include nausea, vomiting and/or abdominal pain, dehydration, deep breathing or breathlessness, extreme drowsiness and/or a fruity odour to the breath.

What causes DKA?

DKA occurs when there is an accumulation of toxic substances called ketones. Ketones are produced when there is not enough insulin in the body. Glucose cannot enter the cells to provide energy which results in a breakdown of fat as an energy source which then results in ketones being produced. Ketones are a form of pollution in the blood. They make the blood too acidic and this can result in the person becoming seriously unwell very quickly. This condition requires immediate medical management.

Managing Type 1 diabetes

Everyday illnesses, infection, or missed doses of insulin will nearly always cause a rise in BGLs in someone with Type 1 diabetes. Therefore, at the earliest sign of any form of illness or elevated blood glucose levels it is important that you follow your child’s personalised sick day management plan or seek a medical review immediately.

• Your child should always take insulin (especially basal insulin even if they are not eating as this will keep the BGL down. They may need a small dose of fast-acting insulin to lower their BGL). Small children with an upset stomach may need less insulin if they are not eating and drinking, but never stop insulin completely. Your child’s diabetes team will have provided a sick-day plan to follow, but if in doubt ring for further advice.
• Test for ketones – especially if BGL is greater than 15.0 mmol (millimoles per litre) on two consecutive occasions or your child is feeling ill.
• Continue to test for ketones every two hours until they are less than 0.6
• BGL should be tested every two hours when your child is unwell and until the ketones have fallen to less than 0.6.
• Encourage your child to keep drinking and eating if possible. Water is very important as it helps flush the ketones out of the body.

Treatment

Most episodes of DKA are mild and can be dealt with at home by following a sick-day plan.

• If BGL is greater than 15mmol make sure you test for ketones. Extra insulin is usually required with frequent BGL and ketone testing.
• When BGL is 15mmol and under it is recommended that you continue to test your child’s BGL every two hours until ketones have fallen to less than 0.6 and glucose is back within target range
• Sometimes a hospital admission may be required.

General ketone action plan

Ketone reading below 0.6mmol/L

Follow your healthcare professional’s advice before making changes to your insulin regimen.

Ketone reading 0.6 to 1.5mmol/L

Contact your health care professional with your child’s current BGL and ketone level results for further instructions.

Ketone reading 1.5mmol/L

Contact your healthcare professional immediately for advice or go to your nearest Emergency department or call 000 if required.

Equipment

Make sure your meter at home is in good working order. This will help to ensure that the BGL and BKL results are accurate. Always make sure there are glucose and ketone strips available and in date.

Things to remember when seeking medical advice

Seek medical advice early for any symptoms of DKA if the glucose and ketone levels don’t settle quickly with your child’s sick-day plan.

Try to provide:

• current blood glucose result
• ketone test level
• your child’s usual total daily dose of both long and short acting insulin.

If your child is admitted to hospital

• Your child’s vital signs (temperature, heart rate, breathing, behaviour etc) will be monitored regularly, even at night.
• Your child will be given the necessary medications as per the doctor’s orders and your child’s emergency management plan.
• Your child may have an intravenous drip to ensure adequate fluid intake and an insulin infusion may be commenced to manage BGL stabilisation.

Transition to home

Your child will be able to go home when your treating doctor considers them to be ready and appropriate for discharge. For example, when:

• Their observations (breathing, heart rate, blood pressure) is within normal limits for their age.
• Their blood results are within acceptable limits for their age and condition.
• They are alert
• Any required care education has been given and explained.

For children with other complex health care needs, we would expect their state of health to be as it was prior to the onset of this current illness.

Care at home

Once at home your child may still be tired. It is important to:

• Encourage them to participate in normal activities as much as possible.
• Follow your child’s diabetes management plan.
• Ensure you are aware of your child’s sick-day plan for any future illnesses.

You will need to make an appointment to see either your GP/paediatrician/diabetes educator within one week of discharge.

When to seek help

See your GP if:

• your child is not improving
• your child is requiring insulin more frequently than your child’s diabetes plan suggests
• you are at all concerned that something may be wrong with your child.

In an emergency, call Triple Zero (000) and ask for an ambulance. You should seek emergency care if:

• your child repeatedly needs more insulin than your plan indicates
• symptoms do not improve after following your child’s sick-day plan.
• your child gets little or no relief or symptoms worsen suddenly.

If you're not sure whether to go to an emergency department, call 13 HEALTH (13 43 25 84) and speak to a registered nurse.

Useful websites

• DRF Type 1 Diabetes
• Diabetes Queensland
• Diabetes Australia

References

• Australian Diabetes Educators Association (ADEA) Sick Day Management Guidelines for People with Diabetes, 2006
• Wales JKH and Dimitri, P. Endocrine and metabolic disorders. Illustrated textbook of paediatrics, 4th edition, 2011. ISBN 978 0 7234 3565 5
  www.medbroadcast.com/channel_condition_info_details.asp?disease_id=154&channel_id=1013&relation_id=5158

Developed by the Endocrinology and Diabetes, Queensland Children’s Hospital. We acknowledge the input of consumers and carers.

Resource ID: FS210. Reviewed: January 2016.

Disclaimer: This information has been produced by healthcare professionals as a guideline only and is intended to support, not replace, discussion with your child’s doctor or healthcare professionals. Information is updated regularly, so please check you are referring to the most recent version. Seek medical advice, as appropriate, for concerns regarding your child’s health.